A Work-Related Health Check to Identify the Need for Rehabilitation and Preventive Care (Check-Up 45+)

A Multicenter Randomized Controlled Trial in General Practice (PReHa45)

Background: General practitioners are the main mediators of rehabilitation and prevention services for their patients, yet many who could benefit from such services do not receive them because there has not, to date, been any structured means of detecting need. We studied the efficacy of a work-related health check for persons aged 45 and over (“check-up 45+”) to identify the need for rehabilitation and preventive care in general practice.

Methods: In a pragmatic, multicenter, 1:1 randomized controlled trial (registration no. DRKS00028303), the participating patients (aged 45 to 59) received, in addition to usual care, either a short questionnaire alone (695 patients) or, additionally, the “check-up 45+” (706 patients), in which the need for rehabilitation or prevention services was assessed with a validated “screening 45+” questionnaire and subsequent evaluation by the general practitioner. The primary endpoint was the number of applications for rehabilitation and prevention services, as determined from routine data derived from the German Pension Insurance (Deutsche Rentenversicherung). The secondary endpoints were approvals of services, actual provision of services, and needs identified by the “check-up 45+”.

Results: Applications for rehabilitation and prevention services were four times more common for patients who received the “check-up 45+” than for those who did not (12.0% vs. 2.9%; p<0.001). The percentages of approved and completed services were higher as well (8.4% vs. 2.4%; 7.2% vs. 2.3%; p<0.001 for both). The “check-up 45+” identified a need for rehabilitation in 17.7% of patients and a need for preventive services in 26.3%.

Conclusion: These findings indicate that the use of the “check-up 45+” in primary care increases the number of applications for rehabilitation and prevention services. The “check-up 45+” can improve needs-based access to rehabilitation and prevention services through early, structured recognition of the patient’s needs and ensuing application for these services.

Cite this as: Burchardi JM, Gellert P, Brünger M: A work-related health check to identify the need for rehabilitation and preventive care (check-up 45+): A multicenter randomized controlled trial in general practice (PReHa45). Dtsch Arztebl Int 2025; 122: 315–20. DOI: 10.3238/arztebl.m2025.0055

Many people of working age feel compelled to take early retirement for health reasons. In Germany, four in ten people receive a disability pension without having undergone rehabilitation, even though “rehabilitation before retirement” is an accepted principle (1, 2, 3). Evidence suggests that rehabilitation can prolong the working years before retirement for reasons of disability (4, 5). It has, therefore been suggested that rehabilitation measures should be made more accessible (6, 7, 8).

According to the German Flexible Retirement Act (Flexirentengesetz), German Pension Insurance (Deutsche Rentenversicherung, DRV) should endeavor to provide voluntary, individual, job-related health care to insurees aged 45 and over (Section 14 of Book VI of the Social Code). The DRV provides rehabilitation for people of working age as well as multimodal prevention services in a program entitled “RV Fit” (www.rv-fit.de). These consist of approximately six months of combined training in exercise, nutrition, and stress management while the participants are working, framed by two inpatient or full-day outpatient treatments in rehabilitation facilities for a total of 4–8 days (9). Both of these services are provided only to participants who actively apply for them.

General practitioners play an essential role in coordinating the application process (10). No systematic screening process in primary care has yet been established to determine the need for rehabilitation or preventive services; various approaches to screening that have been tested in randomized, controlled trials have not been found to be effective (11). Moreover many people who need such services fail to apply for them (12). In pertinent surveys, both patients and general practitioners have said they are inadequately informed about the possible need for rehabilitation measures, what these consist of, and how to apply for them; other reported problems include the (subjectively) high administrative burden of applying, low expectations that applications will be approved, and non-transparent criteria for rejection. There may also be personal or professional considerations that deter patients from applying (10, 13, 14).

We carried out a multicenter randomized trial (PReHa45) to evaluate the effectiveness of a check-up 45+ to identify the need for rehabilitation and prevention services in primary care.

Methods

Trial design

PReHa45 is a pragmatic, two-armed, 1:1 randomized controlled trial that was carried out in 26 general medical practices in the German federal states of Berlin and Brandenburg. It was prospectively entered in the German Clinical Trials Registry (DRKS00028303, UTN U11111–1275–0063). The methods of the trial have been described in detail in a published protocol (15). Trial reporting is in accordance with the CONSORT statement (16).

Participants and trial procedure

The staff of the general practices independently recruited persons aged 45 to 59 who presented themselves at the practices for any reason. Persons who were suitable for inclusion (for inclusion and exclusion criteria, see eMethods) were given questionnaires in sealed envelopes and asked to fill them out in the waiting room. The envelopes bore no indication of the assignment of the patient to the intervention or control group; this ensured blinding of the practice staff at the time of invitation to participate in the trial.

Intervention (check-up 45+)

The intervention group underwent a work-related health check, called “check-up 45+,” in addition to usual care. These participants filled out a psychometrically validated, two-page questionnaire, called “screening 45+,” in the practice waiting room (17). The answers to this questionnaire are rated along five dimensions to identify the need for rehabilitation and prevention services (see eMethods). Sociodemographic characteristics were collected in a further brief questionnaire (eSupplement).

The completed screening 45+ was then evaluated by the practice staff with an algorithm based on predefined thresholds (Table 1). Recommendations based on screening 45+ were reviewed by the practices and modified if necessary. If a need for rehabilitation and prevention services was identified, information and application documents were provided (eSupplement) (15). Part of the intervention consisted of a simplification of the usual process of applying for rehabilitation (see eMethods).

Table 1

Dimensions, value ranges, and recommendations of screening 45+

Control group

The control group received usual care and filled out a short questionnaire (eSupplement) on sociodemographic characteristics while in the waiting room (15).

Endpoints

The primary endpoint was the cumulative percentage applications for rehabilitation and prevention services within two months of their participation in the trial. The secondary endpoints were the percentages of approved applications and of completed medical rehabilitation and prevention services among all participants, provided that the application was applied for within two months of participation. These endpoints were assessed with routine data from the DRV. The prevalence of need for rehabilitation and prevention services was determined for the intervention group from the check-up 45+ (15).

Statistical methods

We calculated the number of participants that would be needed to detect a difference between trial groups with a two-sided Fisher‘s exact test with alpha set at 0.05 and a power of 0.85. For this calculation, we assumed that the percentages of participants submitting applications would be 0.73% in the control group, as implied by the DRV rehabilitation statistics (18), and 3.2% in the intervention group, as implied by two preliminary studies (12, 17). It was concluded that at least 661 participants would have to be included in each group. A dropout rate of 20% due to non-fulfillment of the inclusion and exclusion criteria was assumed (eDiagram).

The analyses were performed according to the intention-to-treat principle. For the primary and secondary endpoints, the absolute and relative frequencies and their 95% confidence intervals were stratified according to trial group. Differences between the trial groups with respect to the primary endpoint were tested for statistical significance with the Fisher exact test, alpha = 0.05 (two-sided). Exploratory subgroup analyses were used to describe differences in rehabilitation applications depending on various characteristics (15, 19).

Results

1401 participants (706 in the intervention group and 695 in the control group) were ultimately included in the analyses (eFigure). The participation rate was approximately 90%. The two trial groups were comparable in all sample characteristics. In the intervention group, the mean age was 52.1 years, and 64.2% were women; in the control group, the mean age was 52.5 years, and 63.0% were women (Table 2).

Table 2

Sample characteristics at baseline (N = 1401)

eFigure

CONSORT flowchart

Primary endpoint

The primary and secondary endpoints are shown in Table 3. The percentage of participants applying for medical rehabilitation or prevention services within two months of their participation was four times higher in the intervention group than in the control group (85 persons, or 12.0%, versus 20 persons, or 2.9%; p < 0.001). This corresponds to an absolute risk difference of 9.2% (95% confidence interval [6.5; 11.9]) and a number needed to screen of 11. In other words, 11 people would need to undergo a check-up 45+ for one additional application for rehabilitation or prevention services to be submitted to the DRV. Far more applications were submitted for rehabilitation than for prevention services; in the control group, not a single application for prevention services was submitted during the observation period.

Table 3

Results: primary and secondary endpoints (intention-to-treat population)

Secondary endpoints

The percentage of services approved based on applications submitted within two months of trial participation was 8.4% (59 persons) in the intervention group and 2.4% (17 persons) in the control group (p < 0.001). The percentage of applications that were approved was 69.4% in the intervention group and 85% in the control group. Among all persons in the check-up 45+ intervention group, 7.2% completed a rehabilitation or prevention service based on an application submitted within two months of their participation in the trial, compared to only 2.3% in the control group (p < 0.001). 86.4% of the approved services in the intervention group and 94.1% in the control group had been completed by the time the data was collected. It should be noted that there was sometimes a long delay between the application or approval and the actual use of the services.

An analysis of applications submitted in the first 12 months of the recruitment phase (up to 30 April 2023) showed that 100% of the approved services were completed.

The prevalence of a need for rehabilitation according to the check-up 45+ was 17.7%, while the prevalence of a need for preventive services was 26.3%. The remaining 55.9% did not need either.

Subgroup analyses

In subgroup analyses of the primary endpoint, applications for rehabilitation were found to be more common among women, older people, and people without vocational qualifications. Applications were particularly common among persons with poor subjective ability to work, 6 weeks or more of medical inability to work in the preceding year, and a high disability pension risk index (Table 4).

Table 4

Subgroup analysis of applications for rehabilitation

Discussion

The intergroup differences in the primary and secondary endpoints confirm the efficacy of the check-up 45+ in primary care. The percentages of applications, approvals, and completed medical rehabilitation and prevention services were markedly higher in persons who had underwent the check-up 45+ than in the control group, and the differences were statistically significant. When interpreting the results, one should bear in mind that applications submitted via other channels (e.g., specialist practices) were also included in the statistics for both groups. This circumstance would tend to dilute intergroup differences, making the observed magnitude of the differences all the more remarkable.

In five out of six cases, the general practitioners followed the screening recommendations of the screening 45+; in most of the remaining cases, the general practitioners identified a higher need than the screening 45+. Other already known information such as existing diagnoses, symptoms, and social or occupational context led in some cases to a different recommendation.

The PReHa45 trial showed that the intervention effectively increased the percentage of applications for medical rehabilitation. In contrast, two other randomized controlled trials did not find any such efficacy for either an online rehabilitation needs test (OREST) (20) or a web-based information guide (21). Apparently, such interventions are not likely to be effective if they are not embedded in existing health care structures, particularly primary care.

In a non-randomized, controlled intervention trial with the participation of 280 patients from five general medical practices, the health check-up offered by statutory health insurance in Germany was extended to include a subjective assessment of ability to work by means of the Work Ability Index (22). This trial confirmed the importance of placing greater emphasis on the topics of ability to work and occupational stress in primary care (23, 24). Other dimensions were not assessed. In contrast, the check-up 45+ in the PReHa45 trial follows a more comprehensive, multidimensional approach based on the biopsychosocial model.

The low rate of applications for DRV prevention services is possibly due to a lack of awareness of the RV Fit program among insurees and their primary care physicians and to a possible preference for other services, such as those offered by health insurance companies. Recent public awareness campaigns by the DRV have already increased application rates, according to recent figures (25), and are paving the way for the nationwide expansion of the prevention services of the DRV (26).

According to subgroup analyses, persons with lower socioeconomic status and more severe health- and work-related impairment had greater need of services and applied for them more frequently. This difference was less marked within the control group, suggesting that additional applications were made in accordance with needs as a result of the check-up 45+. These subgroup findings are plausible and in accordance with the findings of other trials on factors affecting the intention to apply for rehabilitation. These highlighted the importance of low socioeconomic status, poor general health, poor subjective ability to work, and having already undergone rehabilitation (10, 27, 28, 29, 30).

Moreover, support from physicians is crucial for patients’ intention to submit applications for rehabilitation, as well as for the actual submission (28, 29, 31). There is a substantial need for patient education and support regarding applications for rehabilitation (12, 14, 32). The findings of a population-based survey suggest that patients are poorly informed about medical rehabilitation in general, and about the application process in particular. 67% of the working respondents named their general practitioner’s practice as the first point of contact for obtaining information should a need for rehabilitation arise (10). This underscores the importance of making more information available to doctors (12).

More than 80% of working people aged 45 to 64 consult a GP within a year (33). People with lower levels of formal education consult their family doctors significantly more often than others (33, 34). This group is also subject to above-average morbidity and mortality and has a higher need for rehabilitation and prevention services (35, 36).

General medical practices are a good setting for identifying needs and reaching a broad target group. The check-up 45+ took place in this familiar environment and required only a minimum amount of time. Participants did not have to make a separate appointment for it. General practices can also heighten awareness and knowledge of rehabilitation and prevention services. Patients can be proactively informed and counseled there, and, if necessary, assisted with the submission of their applications.

The structure of the application documents is very important as well. General practitioners also report in other studies that the bureaucratic effort involved in submitting an application is a major challenge (24). We therefore simplified the application procedure in this trial by markedly shortening the medical report. The re-structure of a shortened medical report is also the aim of another study involving general practitioners and pension insurance carriers (37).

One strength of this randomized and controlled trial is its pragmatic multicenter design. This enabled the evaluation of the check-up 45+ under the conditions of routine care. The involved practices covered a broad spectrum in terms of practice structure (single-doctor, group practice, health care centers; low to high number of prescriptions) and the social structure of the practice environment (low to high in urban, suburban, and rural locations). Further strengths include the objectively selected endpoints that could be ascertained from DRV routine data, the high sample size corresponding to the calculated power, and the high patient participation rate. When interpreting the findings, one must bear in mind that both the structured needs assessment and the simplified rehabilitation application procedure are likely to have had a major effect in increasing the percentage of rehabilitation applications.

As for the secondary endpoint of the estimation of the prevalence of need, one possible limitation is that especially motivated practices with an interest in identifying needs for rehabilitation and prevention were perhaps more likely than others to participate in the trial. Nor can it be ruled out that some medical practices may have selectively approached their patients to participate in the trial, leading to an overestimate of the true need for rehabilitation and preventive services in general practice. Moreover, when interpreting the subgroup analyses, one must consider that the stratification resulted in a small number of cases at the subgroup level, which led to uncertainties. A further limitation is that only patients with good German language skills could be included in the trial; for implementation, a broader target group would be desirable. Persons with a migration background face higher barriers to access to medical rehabilitation (38), and thus a multilingual screening 45+ would be helpful.

General practitioners play a crucial role. They are responsible for integrating medical rehabilitation into the overall care process. The check-up 45+ can help them improve their patients’ access to rehabilitation and prevention services through an early, structured assessment of need, followed by application. The screening 45+ with an algorithm-based evaluation provides a good take-off point for GPs for the assessment of need, but the final medical evaluation in the check-up 45+ process is crucial. The findings of this trial serve as the first comprehensive evidential basis for integrating a check-up 45+ to determine the need for rehabilitation and prevention services into standard primary care. The coalition agreement of the new German federal government foresees the implementation of a check-up 45+ in standard care (39).

The consequences of introducing the check-up 45+ in standard care depend on the framework conditions. If a one-time entitlement to a check-up 45+ is introduced in general practices and made use of by 75% of those eligible—analogously to the current utilization of health check-ups by statutory health insurance carriers, and in line with the effects observed in this trial—then a modest increase of approximately 3% in rehabilitation applications, services, and costs can be expected (40). This increase is well below the usual annual fluctuations in the utilization of rehabilitation services (25). On a purely financial level, the projected additional costs of rehabilitation should be weighed against the savings achieved by providing rehabilitation services to those who need it, including deferral of work cessation and disability pensions (5).

Data sharing statement

The primary data of this trial can be made available in anonymized form to individual researchers upon submission of an application to [e-mail] containing an explanation of the reason for the request and of the appropriate research methods that are intended to be used. The trial data will be kept for no longer than ten years after the end of the trial in accordance with the relevant data protection regulations.

Financing

This study was financially supported by Deutsche Rentenversicherung Berlin-Brandenburg (project number 10-R-40.07.05.07.023).

Acknowledgment

We thank the participating patients and general medical practices, Deutsche Rentenversicherung Berlin-Brandenburg, and Deutsche Rentenversicherung Bund for supporting this trial. We also thank Susanne Rossek and Christin Lissat for their help with data acquisition.

Conflict of interest statement
The authors state that they have no conflicts of interest.

Manuscript received on 18 December 2024, revised version accepted on 20 March 2024.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Jennifer Marie Burchardi

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