Clinical practice guidelines are relevant to all parties involved in the health system. For rehabilitation under the German pension insurance scheme, there are two main aspects: the integration of rehabilitation into the curative guidelines in terms of "local tailoring" on the one hand and the development of guidelines for rehabilitative processes, demand-oriented control of rehabilitation access, and rehabilitative aftercare on the other hand. The elaboration of effective standards is aimed at avoiding over-provision, under-provision or misdirected provision of care and, simultaneously, at ensuring that quality assured treatment is offered to the rehabilitees. Also, it is intended to increasingly implement evidence-based medicine in a sector of the health system in which research has so far been underrepresented. Implementation of guidelines in the rehabilitative sector will allow to disseminate existing knowledge in targeted manner, to systematically fill the gaps and to broaden the knowledge base as a whole. Furthermore, guidelines can facilitate integration of the different sectors in health care provision by operationalising the interfaces both with curative medicine and primary prevention. Throughout the process of guideline development for rehabilitation the specific characteristics of this sector must be kept in mind. Since therapeutic interventions are multidisciplinary and multimodal in nature guidelines have to be comprehensible and applicable for all members of the multiprofessional team. Corresponding to the relative paucity in rehabilitation research there is no sufficient evidence base for numerous therapeutic interventions. Accordingly, guidelines in rehabilitation will--initially--consist of a mixture of evidence- and consensus-based recommendations. Also, the specific goal of rehabilitation under the German pension insurance scheme, namely maintenance or recovery of the capacity at work, has to be borne in mind. There are many initiatives by the providers of rehabilitation as well as the scientific medical societies to develop and implement rehabilitative clinical practice guidelines, e. g. the guidelines programme of the BfA (Federal Insurance Institute for Salaried Employees), which is aimed at developing rehabilitation process guidelines for selected indications, the guidelines activities of the VDR (Federation of German Pension Insurance Institutes), and the input of the "Guidelines" commission of the DGRW (German Society of Rehabilitation Science). It is hoped that in the years to come the parties involved in German health care provision will be open to the advantages of clinical practice guidelines. Rehabilitation under the German pension insurance scheme, with respect to its experience with quality assurance, its responsibilities for structure and concept and a growing acceptance on the part of care providers, already holds a well-founded starting position.

Using routine data collected in 2000 for the quality assurance programme of the German Pension Insurance subjective mental impairment and disorders documented in discharge letters of patients undergoing rehabilitation funded by the Federal Insurance Institute for Salaried Employees (BfA) (n = 19,272) were correlated with psychological treatment and inpatient somato-medical rehabilitation provided. The results show discrepancies between self-evaluation, original diagnosis and treatment received. The frequency of treatments varies between hospitals. The differences in treatment are attributed rather to a varying quality of implementation of the bio-psycho-social concept than to a lack of human resources.

Health-related strategies aimed at ensuring long-term participation in working life are gaining increasing importance against a background of longer working lives and demographic change. Medical and vocational rehabilitation under the German statutory pension insurance scheme are among these strategies. For a long time already, preventive concepts have been taken into account in rehabilitation so that the pension insurance's prevention approach is mainly based on the experience gained with preventive-modules in rehabilitation and follow-up care. Having so far only been able to offer in-patient prevention benefits, the statutory pension insurance scheme now can offer out-patient prevention measures, given the amendment it initiated to change Section 31 (1) no. 2 of Book 6 of the German Social Code which came into effect on January 1, 2009. The common guidelines of the statutory pension insurance institutions directed at ensuring continued working capacity were revised relative to the preventive benefits contained and were supplemented by recommendations for their use. The changing occupational demands in modern service society have thus been taken into account, and prevention benefits can be implemented in a more flexible manner following successful trials. The concept of out-patient prevention measures following along at the workplace and during leisure time is intended to enhance sustainability of acquired health-promoting behaviours in every day (working) life. At present this new concept is being tried out in various circumscribed pilot projects by several pension insurance institutions, partly in combination with in-patient components. On account of their specific know-how and their regional networks with enterprises, rehabilitation facilities are destined as locations for carrying out pension insurance prevention benefits.

Clinical practice guidelines - seen as an aggregation of scientific evidence - and evidence based medicine are of relevance and importance for everybody involved in health care. Nevertheless, the discussion of their pros and cons is controversial. Major criticisms concern methodological aspects, a disregard of the patients' perspective, potentially increasing costs and the limitation of doctors' autonomy possibly caused by streamlining therapy. Supporters emphasize the improvement of care that comes with using proven therapies, patients' empowerment, cost reduction and equity in the distribution of resources. Following medical practice guidelines the liability for medical malpractice may be limited, but non-adherence to guidelines does not entail liability per se. Clinical practice guidelines in the rehabilitative sector differ from those in curative medicine by being required to achieve more complex goals than maintenance, recovery and improvement of health. Activities in the rehabilitation sector address two main topics: The integration of rehabilitation into curative guidelines, e. g. by participating in the German clearing process for guidelines, and the development of guidelines specific to rehabilitation. There are a number of guideline initiatives, e. g. with the Association of the Scientific Medical Societies (AWMF), the Federation of German Pension Insurance Institutes (VDR) and the Federal Insurance Institute for Salaried Employees (BfA). The BfA project is the first to allow integration of evidence based medicine into the quality assurance programme of the German Pension Insurance complementing it with differentiated criteria for the assessment of therapeutic processes. Taking evidence based medicine increasingly into consideration and the continuous process of introducing rehabilitative clinical practice guidelines are going to improve health care for people with chronic diseases.

Over the past 20 years the German Pension Insurance has rehabilitated nearly 800,000 patients with coronary heart disease. In particular, phase-II rehabilitation has been established as an integral part of cardiac patient care. However, the decreasing number of participants in phase-III must be seen critically. Today's cardiac rehabilitation is characterised by evidence-based treatment modules and a sophisticated quality assurance system that ensures quality orientation in all aspects, from access to rehabilitation through to aftercare. Future developments such as vocationally-oriented medical rehabilitation and the use of new technologies will further improve cardiac rehabilitation. Positive patient feedback and scientific evidence of the effectiveness of cardiac rehabilitation are further incentives to maintain this forward-looking approach.