Complementary Therapies in Medicine (2013) 21, 669674

Available online at www.sciencedirect.com

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journal homepage: www.elsevierhealth.com/journals/ctim

Physiotherapy as one column of an

integrative and interdisciplinary medical
approachImpact of the introduction of
diagnosis related groups in Germany
Tobias Romeyke a,b,, Hans Christoph Scheuer b,
Harald Stummer a,1
a

Department for Public Health and Health Technology Assessment, University for Health Sciences, Medical
Informatics and Technology, Division for Organizational Behavior Research and Workplace Health
Promotion, Opernring 5/2, 1010 Vienna, Austria
b
Department of Acute Internal and Integrative Medicine, Waldhausklinik Deuringen, Germany
Available online 1 September 2013

KEYWORDS
Physiotherapy;
Interdisciplinary
therapeutic
approach;
DRG;
Case tariff fee;
Germany;
Effects

Summary
Objectives: To investigate the introduction of case tariff fee remuneration as required by
the current system and its inuence on patient satisfaction with the provision of physiotherapeutic treatment in an acute hospital aligned on a holistic, interdisciplinary therapeutic
approach.
Design and setting: Randomised controlled study with a total of 4598 patients were interviewed.
No case tariff fee system was used during the years 2004 to 2006. The data were compared
with the results of interviews that took place during 2007 and 2008 (use of DRGs). The results
of this study are based on the largest survey performed to date of patient satisfaction with
physiotherapeutic treatment in acute care focusing on a holistic interdisciplinary approach.
In-patients being treated under DRG conditions were compared with a control group for whom
the DRG system had not been applied.
Outcome measures: The target parameter of the study, which took more than ve years, was
the determination of patient satisfaction with the physiotherapeutic interventions.
Results: There were no signicant differences between the two groups in respect of satisfaction with the physiotherapeutic treatments received. Regarding the outcome parameter
encouragement to take more exercise, a signicant change could be demonstrated under DRG
conditions.

Corresponding author. Tel.: +43 50 8648 3951; fax: +490821554751.

E-mail addresses: tobias.romeyke@umit.at (T. Romeyke), harald.stummer@umit.at (H. Stummer).
Tel.: +43 50 8648 3951.

0965-2299/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.08.016

670

T. Romeyke et al.
Conclusions: Physiotherapeutic interventions play an important role in the provision of interdisciplinary care. In particular, the holistic perception of the patient, the interdisciplinary approach
to complex diseases, and the requirements of the DRG system on the care provider can exert a
positive inuence on outcome quality.
2013 Elsevier Ltd. All rights reserved.

Introduction
The use of the methods of physiotherapy, and their mechanisms of action, has been the subject of numerous scientic
studies.14
In this context, physiotherapeutic measures play an
especially prominent role not only against diseases and disorders of the musculoskeletal system and connective tissue,5
against multiple pain conditions68 and against cardiac and
vascular diseases,9 but also in the prevention of postoperative complications10,11 and neurological diseases.12,13
Therapy concepts for multi-morbid patients aim at interdisciplinary diagnosis and therapy oriented more strongly
on the patient. Particular multimodal treatment programs
with a focus on integrative complementary medicine play a
special role.14
In doing this, not only is the main disease treated, but
accompanying diseases are also included in the therapeutic
procedure. In order to map different therapeutic and diagnostic measures in different, indication-related treatment
structures, specic complex codes were created in Germany
in collaboration with the medical professional associations
and the DIMDI (German Institute for Medical Documentation
and Information). These complex treatments are based on
the inpatient hospital structure and make it possible not
only to map specialisation, but also to take into account and
assure the structure and process quality in the stationary
setting.15,16
These complex treatments are published in the operations and procedures catalogue (OPS) and can be provided
by specialised hospitals in Germany.
On the basis of evidence based proof of efcacy, physiotherapy/physical therapy was included as a structural
quality criterion in this operations and procedures catalogue
(OPS) for the provision of inpatient care (Fig. 1). The large
number of complex treatments with Physiotherapy/physical
therapy shows their importance.
The DIMDI issues classications for coding diagnoses and
operations, and maintains further medical designation systems. Other key aspects are the maintenance of information
systems for drugs and medical products, and the evaluation
of health-relevant procedures (Health Technology Assessment, HTA).
The German diagnosis related groups system (G-DRG
system) was based on the Australian Rened DRG system
(AR-DRG system).
DRGs dene an economic medical classication system
with which services provided to patients are classied in
case groups according to the admission diagnosis for the
individual case being treated and the types of therapy performed.
The G-DRG system is intended to be a learning system relying on quantitative data supplied to the Institute
for the Hospital Remuneration System (InEK) by the 230

reporting hospitals throughout the year. Hospitals make

their costs data available annually and participate in a procedure leading to proposals for further development of the
system.
Under DRG conditions, the treatment process is prestructured by mandatory requirements. Deviation from the
requirements for the procedure of providing treatment can
lead to loss of entitlement to reimbursement for the services provided. As a result of an increased intensity of
the therapy provided, precise observance of the requirements can lead to intensive or even excessive demands on
the therapeutic personnel. It becomes necessary to monitor the performance of the medical treatments prescribed
during the period of hospitalisation, in particular regarding
whether the requirements of the procedures catalogue are
fullled (for an overview of the procedures, see Fig. 1). Corrective interventions are possible only while the patient is
in an inpatient setting.
The introduction of case tariff fees has strongly increased
the transparency of the type and quantity of treatment provided by the hospitals, and of the costs structures.17

Objective
The aim is to analyse the impact of this reimbursement system in Germany, nationwide, over a longer period of time.
This is also important in view of the introduction of the
G-DRG system in other European and, also, non-European
countries.
German legislators have commissioned a research project
to observe the impact of the introduction of the case tariff
fees in the hospital (Section 17b Abs. 8 Krankenhausgesetz).
This also focusses on possible changes in the structures of
treatment provided. Although of considerable importance,
the effects of the DRG system on quality indicators referring
to the provision of physiotherapeutic treatment have yet
to be studied. To this end, patients are interviewed who
received acute care within an interdisciplinary therapy.

Methods
Patients in an acute hospital aligned on a holistic,
interdisciplinary therapeutic approach (Fig. 1 particular:
naturopathic and anthroposophic complex medical treatment, multimodal pain therapy, rheumatological complex
multimodal treatment) were interviewed over a period of
ve years. Diseases of the patients affecting:

musculoskeletal system and connective tissue

circulatory system
nervous system
respiratory organs
mental disorders.

Physiotherapy as one column of an integrative and interdisciplinary medical approach

671

OPS
OPS 8-972
8-972 Co
Complex
mplex trea
treatment
tment of
of intractab
intractable
le epileps
epilepsyy
OPS
OPS 8-974
8-974 Co
Complex
mplex multimodal
multimodal treatme
treatment
nt in
in other
other chr
chronic
onic diseas
diseasee
turop
OPS
Natu
ropathic
athic and
and anthr
anthropos
oposophi
ophicc co
complex
mplex me
medical
dical trea
treatment
tment
OPS 8-975
8-975 Na
OPS
reatmen
OPS 8-977
8-977 Multimod
Multimodal
al comp
complex
lex nonsu
nonsurgical
rgical ttrea
tmentt of
of the
the muscu
musculoske
loskeletal
letalsys
system
tem
OPS
OPS 8-97d
8-97d Co
Complex
mplex multimodal
multimodal treatme
treatment
nt in
in Par
Parkinson
kinson's
's dise
disease
ase
OPS
OPS 8-981
8-981 Ne
Neurolog
urological
ical compl
complex
ex trea
treatmen
tmentt of
of acute
acute strok
strokee
OPS
OPS 8-982
8-982 Co
Complex
mplex pallia
palliattive
ive trea
treatmen
tmentt
OPS
OPS 8-98
8-9833 Multimod
Multimodal
al rheu
rheumatol
matologi
ogical
cal comp
complex
lex tre
treatmen
atmentt
OPS
Multimodal
al comp
complex
lex trea
treatmen
tmentt of
of diabe
diabetes
tes mellitus
mellitus
OPS 8-984
8-984 Multimod
OPS
thdrawal
OPS 8-985
8-985 Motiva
Motivation
tion trea
treatmen
tmentt of
of add
addicts
icts [qua
[qualified
lified wi
withd
rawal]]
OPS
Multimodal
al comp
complex
lex rheu
rheumatolog
matologica
icall ch
children
ildren treatme
treatment
nt
OPS 8-986
8-986 Multimod
OPS
OPS 8-988
8-988 Spec
Special
ial compl
complex
ex trea
treatmen
tmentt of
of ha
hand
nd
OPS
Day-patien
tientt ge
geria
riattric
ric co
complex
mplex trea
treattmen
mentt
OPS 8-98a
8-98a Day-pa
OPS
Other
her neurolog
neurological
ical co
complex
mplex treatme
treatment
nt of
of ac
acute
ute strok
strokee
OPS 8-98b
8-98b Ot
OPS
OPS 8-98e
8-98e Spec
Specialized
ialized com
complex
plex in
inpatie
patient
nt pa
palliative
lliative tre
treatme
atment
nt
OPS
Multimodal
al pa
pain
in the
therap
rapyy
OPS 8-918
8-918 Multimod
OPS
OPS 8-91b
8-91b Multimod
Multimodal
al pa
pain
in the
therap
rapyy sho
short-cou
rt-course
rse
OPS
Day-ca
-care
re Mu
Multimodal
ltimodal pain
pain ther
therapy
apy
OPS 8-91c
8-91c Day

Figure 1
therapy.

Extract from the German operations and procedure catalog (OPS 2012): procedures with physiotherapy and physical

The largest study published to date on the impact of the

case tariff fee system in Germany on the satisfaction of the
patients in the context of providing physiotherapeutic treatment investigates two periods: The year 01/2004 to 12/2006
(without case tariff fee system) and the year 01/2007 to
12/2008 with use of the G-DRG system. In-patients receiving treatment during these periods were asked the following
questions:
(1)
(2)
(3)
(4)

How do you rate the physiotherapeutic measures?

How do you rate the remedial gymnastics?
Were you encouraged to take more exercise?
How do you rate the overall success of the physiotherapy?

The results of the survey were anonymised so that it was

impossible to draw any conclusions about the gender, status
or age of the patients. The acute hospital surveyed deploys
an interdisciplinary team of physiotherapists, masseurs and
balneotherapists. The data were compared with the results
of survey from the years 2007 and 2008 (use of DRGs). The
following evaluation system was used:
(1)
(2)
(3)
(4)
(5)
(6)

very good
good
satisfactory
sufcient
decient
insufcient.

Statistical evaluations were performed using SPSS for

Windows, Version 19.0 (SPSS Inc., U.S.A.).
The MannWhitney U-test was used for comparing two
independent non-normally distributed samples.

The categorised data, on the other hand, were evaluated using the chi-squared test and Fishers exact test. When
using the chi-squared test, the necessary test requirements
were fullled, such that in all the tests fewer than 20% of
the expected frequencies were smaller than 5. Individual
cases not fullling this test requirement are discussed in
the presentation of the result.
All the tests performed were subjected to a two-sided
signicance test, whereby a p-value < 0.05 was deemed to
be statistically signicant.
The categorised data were displayed graphically using
grouped bar charts.
The one-sided test was used to check whether a positive/negative correlation exists between the variables; the
two-sided test to determine whether any correlation at all
can be detected. In the one-sided test the counterhypothesis
is not checked and, therefore, the probability of error of the
one-sided test is always lower. The two-sided signicance
was checked, as before.
The Fisher test was used as a signicance test in a
2 2 table and is therefore a special form of the crossclassication table. If a 2 2 table is available, the Fisher
test is more accurate than the chi-squared test.

Results
A total of 931 patients have evaluated the physiotherapeutic measures in the two periods. All together,
the measures in both periods were evaluated as very
good. (Period 01/200412/2006,  = standard deviation,
 = mean). N = 416,  = 0.621,  = 1.34.
(Period 01/200712/2008), N = 515,  = 0.711,  = 1.40.

672

Figure 2
tent.

T. Romeyke et al.

Overall successphysiotherapy in both periods con-

There was no signicant deviation in the two periods

(MannWhitney U-test, p 0.05).
A total of 663 patients in the two periods evaluated the
methods from the remedial gymnastics area. The overall
result was a grade of good ( = 1.80).
(Period 01/200412/2006). N = 249,  = 1.155,  = 1.87.
(Period 01/200712/2008), N = 414,  = 0.844,  = 1.77.
Comparison of the two periods revealed no signicant
deviation (MannWhitney U-Test, p 0.05).
The question as to whether the patients received more
incentive to exercise as a result of the physiotherapeutic
methods used was answered by a total of 1457 patients in the
two periods. A signicant change occurred under DRG conditions (chi-squared according to Pearson p 0.05, exact test
according to Fisher p 0.05. 0 cells (0.0%) have an expected
frequency of less than 5). The minimum expected frequency
is 334.78.
The overall success of applying physiotherapeutic methods was evaluated by 908 patients (Fig. 2). Very good success
was reported by 239 patients (Period 01/200412/2006 total
111 patients, Period 01/200712/2008 total 128 patients),
good success by 515 patients (Period 01/200412/2006 total
227 patients, Period 01/200712/2008 total 288 patients),
moderate success by 129 patients (01/200412/2006 total
45 patients, 01/200712/2008 total 84 patients) and no success by 25 patients (01/200412/2006 total 13 patients,
01/200712/2008 total 12 patients). Comparison of the
results with and without case tariff fee system revealed
no signicant difference (chi-squared according to Pearson
p 0.05). 0 cells (0.0%) have an expected frequency of less
than 5. The minimum expected frequency is 10.90.

Discussion and conclusions

Impact of the G-DRG system
The evaluation of the impact of activity-based funding is
largely lacking18 so far it was difcult to draw clear nal
conclusions.19
The introduction of the DRG systems generates a high
incentive to increase numbers of cases,20 with the simultaneous aim of cutting in-house costs.

In a case tariff fee reimbursement system it is possible

to structure the treatment processes while increasing costs
transparency.21
Some studies show that the introduction of the DRGsystem has no signicant effect on the quality.22,23
In addition to the rationalisation and optimisation of
working procedures, staff reductions are also being discussed, or the introduction of various systems for exible
working hours, for example, work on call.24
Introduction of DRGs can also lead to greater time pressure and a greater workload. Adequate interaction with
patients can no longer be guaranteed and treatment can
no longer be taken for granted; moreover, an increase in
the number of complications and in the mortality rates has
been reported.25
Hospitals may also discharge patients earlier than clinically appropriate or pushing the patient into a higher paying
DRG in order to optimise the payments they receive.26

Impact on patient satisfaction in context of an

interdisciplinary medical approach
Patient satisfaction can be regarded as one patient-centred
indicator next to medical outcome.27 Physiotherapy plays
as one column of an integrative and interdisciplinary medical approach an important role in the holistic patient care.
Interdisciplinary therapy programmes also can show a significantly greater efcacy than purely monocausal treatment
approaches.28
These multi-modal therapeutic approaches integrate
numerous methods of physiotherapy29 (Fig. 1) in the OPS.
In the context of an interdisciplinary provision of treatment in the inpatient setting, the patients are also affected
by challenges and developments within the health system.
Integration of the patient in the evaluation of physiotherapeutic treatment quality is the result of an increasing
patient orientation in health care.
In this study it becomes clear that system-related
changes such as the introduction of a new remuneration system (G-DRG system) do not have a decisive impact on patient
satisfaction with the provision of inpatient care.
It allows the conclusion that physiotherapeutic treatment, in the sense of holistic medicine, is used in acute
hospitals in Germany in addition to the methods of orthodox medicine, is evaluated very positively by patients, also
in the changed situation of a case tariff fee system in
Germany.
Rather, as a result of mandatory requirements on the
provision of inpatient treatment, the case tariff fee system in Germany creates the basis for improved structural
and process quality, which can manifest itself in improved
treatment outcomes.
The analysis of patient satisfaction with physiotherapeutic treatment can essentially be inuenced by two factors:
First, everything that can be related to the physiotherapeutic personnel at a personal level; and second, all those
factors which affect the patient as a result of systemrelated or external conditions.30,31 The personal aspects
include, in particular, the outcome of the treatment,32 the
professionalism of the therapists (especially the indicationrelated use of physiotherapeutic treatments mentioned at

Physiotherapy as one column of an integrative and interdisciplinary medical approach

the beginning), information about the therapeutic procedure and explanation of the content and mode of action
of the therapies prescribed, and the time taken by the
therapists31,33 in the context of an integrative treatment
programme.34,35
Indicator of an interdisciplinary inpatient treatment
therapy is a high therapy density.15,36 This was in both time
sections of this study ensured and may also an important
factor contribute to patient satisfaction.
In addition to structural and process quality criteria,
patient satisfaction is deemed to be an important goal and
a central criterion for the acceptance of a treatment.37
This can also be the underlying explanation as to why the
patients under DRG conditions are encouraged to take more
physical exercise. Further studies are necessary to investigate patient satisfaction with physiotherapeutic treatment
in other countries with a case tariff fee remuneration
system.

Conict of interest statement

9.

10.

11.

12.

13.

14.

None of the authors have anything to disclose concerning

possible nancial or personal relationships with commercial
entities that may have a direct or indirect interest in the
subject matter of this presentation.
15.

Source of funding
No source of funding was required.

16.

Acknowledgements
The authors would like to thank the anonymous reviewers
for reviewing the paper.

17.

References

18.

1. Kellerman JJ, Shemesh J. Exercise training of patients with

severe heart failure. Journal of Cardiovascular Pharmacology
1987;10:S17280.
2. Comella CL, Stebbins GT, Brown-Toms N, Goetz CG. Physical
therapy and Parkinsons disease: a controlled clinical trial. Neurology 1994;44:3768.
3. OBrien JG, Chennubhotla SA, Chennubhotla RV. Treatment of
edema. American Family Physician 2005;71:21117.
4. Jane SW, Wilkie DJ, Gallucci BB, Beaton RD, Huang HY. Effects
of a full-body massage on pain intensity, anxiety, and physiological relaxation in Taiwanese patients with metastatic bone
pain: a pilot study. Journal of Pain and Symptom Management
2009;37(4):75462.
5. Smidt N, de Vet H, Bouter L, Dekker J. Effectiveness of exercise therapy: a best-evidence summary of systematic reviews.
Australian Journal of Physiotherapy 2005;51:7185.
6. Fritz JM, Erhard RE, Hagen BF. Segmental instability of the lumbar spine. Physical Therapy 1998;78(8):88996.
7. Schonstein E, Kenny DT, Keating J, Koes BW. Work conditioning,
work hardening and functional restoration for workers with back
and neck pain. The Cochrane Database of Systematic Reviews
2003:3.
8. Castro-Snchez A, Mataran-P
enarrocha GA, Lara-Palomo I,
Saavedra-Her
nandez M, Arroyo-Morales M, Moreno-Lorenzo C.
Hydrotherapy for the treatment of pain in people with multiple

19.

20.

21.

22.

23.

24.

25.

673

sclerosis: a randomized controlled trial. Evidence-Based

Complementary and Alternative Medicine 2012;2012,
http://dx.doi.org/10.1155/2012/473963.
Article
ID
473963.
Hwang CL, Chien CL, Wu YT. Resistance training increases
6-minute walk distance in people with chronic heart failure: a systematic review. Journal of Physiotherapy 2010;56:
8796.
Tucker B, Jenkins S, Davies K, McGann R, Waddell J, Kling
R, et al. The Physiotherapy management of patients undergoing coronary artery surgery: a questionnaire survey. Australian
Journal of Physiotherapy 1996;42:12937.
El-Ansary D, Adams R, Toms L, Elkins M. Sternal instability following coronary artery bypass grafting. Physiotherapy Theory
and Practice 2000;16:2733.
Hildick-Smith M. Has rehabilitation a role in the treatment of
Parkinsons disease? In: Clifford-Rose F, editor. Parkinsons disease: clinical and experimental advances, 6. London: Libbey;
1987.
Stallibrass C, Sissons P, Chalmers C. Randomized controlled trial
of the Alexander technique for idiopathic Parkinsons disease.
Clinical Rehabilitation 2002;16:695708.
Michalsen A, Li C, Kaiser K, Ldtke R, Meier L, Stange
R, Kessler C. In-patient treatment of bromyalgia: a controlled nonrandomized comparison of conventional medicine
versus integrative medicine including fasting therapy. EvidenceBased Complementary and Alternative Medicine 2013;2013,
http://dx.doi.org/10.1155/2013/908610. Article ID 908610.
Romeyke T, Stummer H. Interdisciplinary complex therapies
in inpatient hospital treatment in Germany: evidence from
Germany. Journal of Management & Marketing in Healthcare
2011;4(4):20816.
Heinz J, Fiori W, Heusser P, Ostermann T. Cost analysis
of integrative inpatient treatment based on DRG data:
the example of anthroposophic medicine. Evidence-Based
Complementary and Alternative Medicine 2013;2013,
http://dx.doi.org/10.1155/2013/748932.
Article
ID
748932.
Braun T, Rau F, Die Tuschen KH. DRG-Einfhrung aus gesundheitspolitischer Sicht. Krankenhausreport: Eine Zwischenbilanz;
2007.
Scheller-Kreinsen D, Geissler A, Busse R. The ABC of DRGs. Euro
Observer 2009;11(4):15.
Moreno-Serra R, Wagstaff A. System-wide impacts of hospital payment reforms: evidence from central and eastern
Europe and central Asia. Journal of Health Economics
2010;29(4):585602.
Coffey RM, Louis DZ. Fnfzehn Jahre DRG-basierte Krankenhausvergtung in den USA. In: Arnold M, Litsch M, Schellschmidt
H, editors. Krankenhaus-report. Stuttgart/New York. 2000. p.
3347.
Romeyke T, Stummer H. Clinical pathways as instruments for risk
and cost management in hospitalsa discussion paper. Global
Journal of Health Science 2012;4(2):509.
Farrar S, Yi D, Sutton M, Chalkley M, Sussex J, Scott
A. Has payment by results affected the way that
English hospitals provide care? Difference-in-differences
analysis.
British
Medical
Journal
2009;339:b3047,
http://dx.doi.org/10.1136/bmj.b3047.
Ljunggren B, Sjdn PO. Patient-reported quality of life before,
compared with after a DRG intervention. International Journal
for Quality in Health Care 2003;15(5):43340.
Coffey RM. Case mix in the USA: fteen years of DRG-based
hospital nancing in the United States. CASEMIX Quarterly
1999;1(1):716.
Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of
hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration 2008;38(5):2239.

674
26. Miraldo M, Goddard M, Smith PC. The incentive effects of
payment by results. In: CHE Research Paper 19. London: Dr.
Foster Intelligence; 2006.
27. Law M, Baptiste S, Mills J. Client-centred practice: what does
it mean and does it make a difference? Canadian Journal of
Occupational Therapy 1995;62(5):2507.
28. Taimela S, Takala EP, Asklf T, Seppl K, Parviainen S. Active
treatment of chronic neck pain: a prospective randomized intervention. Spine 2000;25(8):10217.
29. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic
review of interventions and outcomes. Rheumatology (Oxford)
2008;47(5):6708.
30. Monnin D, Perneger TV. Scale to measure patient satisfaction
with physical therapy. Physical Therapy 2002;82(7):68291.
31. Beattie PF, Pinto MB, Nelson MK, Nelson R. Patient satisfaction with outpatient physical therapy: instrument validation.
Physical Therapy 2002;82(6):55765.
32. May SJ. Patient satisfaction with management of back pain. Part
2: An explorative, qualitative study into patients satisfaction
with physiotherapy. Physiotherapy 2001;87:1020.

T. Romeyke et al.
33. Cooper K, Smith BH, Hancock E. Patient-centredness in physiotherapy from the perspective of the chronic low back pain
patient. Physiotherapy 2008;94(3):24452.
34. Lauche R, Cramer H, Moebus S, Paul A, Michalsen A, Langhorst
J, Dobos G. Results of a 2-week inpatient stay at the
Department for Internal and Integrative Medicine: an observational study. Evidence-Based Complementary and Alternative
Medicine 2012;2012, http://dx.doi.org/10.1155/2012/875874.
Article ID 875874.
35. Romeyke T, Stummer H. A study of costs and length
of stay of inpatient naturopathyevidence from Germany.
Complementary Therapies in Clinical Practice 2011;17(2):
905.
36. Romeyke T, Stummer H. Economic aspects of nursing in inpatient naturopathy: evidence from Germany. Nursing Economics
2013;31(3):13743.
37. Hannver W, Dogs CP, Kordy H. Patientenzufriedenheit ein
Ma fr den Behandlungserfolg? Psychotherapeut 2000;45:
292300.

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