German Statutory Pension Insurance Research Articles

Does Vocational Reintegration After Medical Rehabilitation Differ in Terms of Social Status and Type of Rehabilitative Care?

Employees in a low socio-economic position (SEP) are more likely to leave the labour market after medical rehabilitation for health reasons than those in a better social position. So far, almost nothing is known about whether certain types of rehabilitative care can reduce this inequality in rehabilitation success. This paper examines whether certain types of care modify the SEP's influence on return-to-work (RTW). The study is based on administrative data from the German statutory pension insurance on 266,413 medical rehabilitations of 253,311 persons fully integrated into working life. Poisson regression analyses were used to check whether there was a correlation between SEP (income, education, occupational position) and the probability of RTW in the year following the measure, and whether this correlation was lower in follow-up treatment (AHB), inpatient treatment or treatment with subsequent graded RTW compared to rehabilitation that did not meet these characteristics. People with a low income, education or occupational position were at increased risk of incomplete return to work after medical rehabilitation. This correlation was comparatively lower for all 3 SEP indicators when the return to work was gradual. In the case of AHB and inpatient rehabilitation, this only applied to income. Socio-economically disadvantaged population groups are comparatively more likely not to return fully to work after medical rehabilitation. These inequalities are less pronounced for certain types of rehabilitative care. This tends to be the case with an active structuring role of the care system. However, there is a need for further research on the modification of effects by the type of treatment. This should be further investigated using data collected for this purpose to exclude selection effects.

Social inequalities in medical rehabilitation outcomes—a registry-based study on 219 584 insured persons in Germany

Given limited knowledge on the extent of social inequalities in longer-term work ability of people with a chronic disease, this study analyzes social inequalities of three consecutive indicators of work ability following medical rehabilitation in a large sample of insured employees. Based on data from the German statutory pension insurance, a representative 20% random sample of all employed persons undergoing medical rehabilitation between 2006 and 2008 was included in a longitudinal analysis (n=219584 persons). Three measures of consecutive work-related outcomes (physicians' assessment of work ability at discharge; return to work in the year thereafter; disability pension during follow-up) and socioeconomic position (SEP) (education, occupational position and income) were assessed. Adjusted relative risks (RRs) for each outcome were calculated according to SEP, applying Poisson regression analysis. The measures of SEP were associated with all three outcomes of work ability in the fully adjusted models. Relatively strongest relationships were observed for education as SEP measure, and they were particularly pronounced for 'low work ability' (RR=2.38 for lower secondary education compared to tertiary education; 95% CI: 2.26-2.51). Based on average marginal effects, absolute differences of work ability by SEP indicate a socially graded pattern, with only few exceptions. Despite Germany's universal access to medical and vocational rehabilitation social inequalities in longer-term work ability following chronic disease persist, thus calling for targeted programmes of prevention and occupational health promotion.

Breast cancer patients’ return to work (B-CARE): protocol of a longitudinal mixed-methods study aiming to explore medical and occupational rehabilitation of patients with breast cancer in Germany

IntroductionIn recent years, research has been done on determinants of return to work (RTW) in cancer survivors and their long-term work outcomes. Nevertheless, little is known about the survivors’ evaluation...

Quality management in medical rehabilitative care by the German statutory pension insurance scheme.

This paper aims to provide an insight into the quality management approach for medical rehabilitation services of the German statutory pension insurance scheme. In the 1990s, the German statutory pension insurance scheme initiated a quality management programme in rehabilitation, which is subject to continuous development. The main objective of implementing quality management in rehabilitative care was quality control and quality improvement. To achieve these goals, five main tools for quality measurements were applied: a classification of therapeutic services, standards of rehabilitative interventions, patient surveys, peer review, and surveys that address structure of care. These tools enable the assessment of the structural and process quality of rehabilitative care, as well as aspects of rehabilitation outcome. As a result, quality of rehabilitation care becomes more measurable, transparent, and hence can be improved on well-founded grounds. These measurements allow implementing comparisons and benchmarking of rehabilitation facilities, thereby creating incentives for quality improvements. Therefore, the development and implementation of quality management measures in facilities of inpatient and outpatient medical rehabilitation is an ongoing process and expands to other areas of rehabilitation.

Two-Part Models and Quantile Regression for the Analysis of Survey Data With a Spike. The Example of Satisfaction With Health Care.

Background: Results of patient satisfaction questionnaires can contain a spike at the value corresponding to a complete satisfaction. A possible interpretation is that there are two types of respondents, those who are willing to provide a negative evaluation to one or more items proposed in the questionnaire and those who will always provide a completely positive evaluation irrespective of the item. The aim of the present study is to compare various statistical approaches to the analysis of such data using data from a rehabilitation patient survey of the German Statutory Pension Insurance Scheme as an example.Method: We used data from 272,806 respondents who participated in the survey from 2008 to 2011. We illustrate four models: linear regression, logistic regression, a two-part model based on the assumption of two underlying populations and quantile regression, which does not require any distributional assumptions. For each model we consider the relationship of the satisfaction score with two covariates.Results: While providing correct estimates of the mean values (marginal effects), the assumptions of the linear model are violated which can lead to false interpretations. A two-part regression which consists of a logistic regression followed by a linear regression conditional on not being fully satisfied is a useful alternative. For research questions focusing on specific parts of the distribution, logistic regression as well as quantile regression are to be considered.Discussion: Data with a spike represents a statistical challenge but a range of modeling approaches is available to provide sound interpretations and correct answers to research questions.

Risk of Reduced Earning Capacity Pension due to Cardiovascular Diseases after Medical Rehabilitation: An Event History Analysis based on German Statutory Pension Insurance Data

Not much is known on risks for reduced earning capacity pensions (RECP) for patients with specific diseases. Our study focusses on individuals who have completed a course of rehabilitation due to cardiovascular disease. This study is based on a scientific use file from the German statutory pension insurance that covers completed rehabilitations between 2006-2013. Using survival analysis, we modeled the transition into RECP in general and for specific diagnostic groups. We used Kaplan-Meier-estimates and age-standardized and sex-specific transition rates. Multivariate Cox Proportional Hazard models are used to identify the most important socio-demographic risk factors for RECP. Patients who completed rehabilitation after cerebral infarction, cardiomyopathy or cerebrovascular diseases were most likely to transition into RECP due to these diseases. The most important socio-demographic risk factors for RECP were low educational attainments, part-time or no employment and living in Eastern Germany. Especially patients with cerebral infarction, cardiomyopathy or cerebrovascular diseases require successful medical rehabilitation. In case of multimorbid patients, these diagnoses require special attention. Also, the reintegration into the labor market of people from lower social strata after medical rehabilitation to avoid RECP appears to be especially difficult.

Potentials of the Third German Socio-Medical Panel of Employees (GSPE-III) for Research in the Field of Migration and Rehabilitation: The Example of Utilization of Rehabilitative Care

The majority of previous studies shows that migrants use medical rehabilitation less often than non-migrants. In some cases, opposite results have been reported. Previous research, however, has different limitations. The present study examines the use of rehabilitation among migrants and non-migrants by means of the Third German Socio-medical Panel of Employees (GSPE-III). The study is based on the first wave of the GSPE-III, extended by administrative data from the insurance accounts of the respective study participants. The survey was conducted in May 2013 and comprises a risk cohort of insurants of the German Statutory Pension Insurance Scheme (Deutsche Rentenversicherung Bund) who are at risk of reduced social participation and who received sickness benefits in 2012. We compared non-German nationals, German nationals with a migration background and German nationals without a migration background. Based on the Andersen Healthcare Utilization Model, the quality of life, the self-perceived risk of a reduced earning capacity as well as demographic and socio-economic factors were taken into account as covariates using a logistic regression model. Of the 2,413 respondents surveyed, 2.7% were foreign nationals and 4.4% were German nationals with a migration background. As compared to Germans with no migration background, Germans with a migration background and non-German nationals did not significantly differ in their utilization of rehabilitation (adjusted odds ratio=0.78, 95%-CI=0.47-1.30 and adjusted odds ratio=0.99; 95%-CI=0.53-1.88, respectively). The GSPE-III allows overcoming some limitations of previous studies by means of detailed data on migration background as well as the possibility to consider confounding factors at different levels and to link survey with routine data. The results contradict the majority of previous studies and show that epidemiological research on the utilization of rehabilitative care among migrants is inconsistent. For the interpretation of the present findings, it is also necessary to take into account the special properties of the GSPE-III and the comparatively small sample size.

Inpatient Rehabilitation for Children and Adolescents With Diabetes in Germany Between 2006 and 2013.

In Germany, inpatient rehabilitation is a well-established additive option in the therapeutic concept for children and adolescents with diabetes. However, its contribution in pediatric diabetes care is not known exactly. Our objective was to analyze inpatient rehabilitation in pediatric diabetes over eight years in Germany. We requested secondary data from the German Statutory Pension Insurance Scheme to evaluate all completed inpatient rehabilitations for children and adolescents with diabetes (ICD-code E10-14) reimbursed by this institution between 2006 and 2013. For each type of diabetes, we analyzed the distribution of admissions by year, age-group, sex, nationality, and other documented diagnoses. All analyses were conducted via remote computing with IBM SPSS Version 24. Between 2006 and 2013, 5,403 admissions to inpatient rehabilitation for 4,746 children and adolescents with diabetes were documented. For type 1 diabetes (T1D; 88.5% of admissions), the number of yearly admissions increased from 458 in 2006 to 688 in 2013 (p=0.013), especially for age-group>5-10. The increase for type 2 diabetes (T2D) was not significant. Admissions were more frequent for girls (53.6%, p≤0.001), age>10-15 years (42.8%, p=0.001), and German nationality (98.5%). Obesity (T1D: 11.1%; T2D: 87.9%) and mental disorders (T1D: 11.6%; T2D: 27.4%) were the most frequent documented diagnoses in addition to diabetes. This study provides a comprehensive overview of inpatient rehabilitation for children and adolescents with diabetes over many years in Germany. Until 2013, inpatient rehabilitation remained important in pediatric diabetes care, especially for children with mental disorders or obesity.

Pneumological Assessment with Regard to Performance Demands - Concept: "Load to Capacity"

Professional opinions on and assessments of physical performance must be oriented to the individual capacity of the person in question. Moreover, this performance has to be correlated with the expected physical load at work, sports activities or operative stress. This "Load to Capacity Concept" is already a part of an integrative medical assessment, based on clinical experience and common sense, rather than on diagnostic numerical values. An evaluation of work intensity in the context of socio-medical assessment ("light - moderate - severe - very severe", German Statutory Pension Insurance, based on the German REFAClassification) can now be complemented by well accessible and valid data based on measurements of real-life and professional activities. Also the ratio of continuous power in view of the maximal power output (V'O2 peak) and the power at the aerobic-anaerobic threshold (V'O2 at VT1) is well established. This information is gained by ergospirometry (CPET - Cardio Pulmonary Exercise Testing). The focus while interpreting the performance lies on Watt as a physical parameter and on O2-consumption (V'O2 L/min) as the crucial biological correlate. V'O2 is presented as a direct value (L/min) or in complex values like MET (Metabolic Equivalent of Task) and calories (kcal).Recent studies can take advantage of technical progress in this field: rapid sensory measurement, convenient display in graphs and tables. In earlier literature there is ample information on working demands and energy expenditure, supplemented by V'O2-data and MET (see Ainsworth et al.). These studies are helpful for orientation. However, it has to be kept in mind that these studies were done with technical possibilities available then, mostly in a laboratory setting, not under real-life conditions. Portable ergospirometry was not available at that time. Ergospirometry has already proved to be a useful tool in cases where expert opinion is required on compensation claims or questions of early retirement. Positive results of our study on "Occupational Activity of Cleaning Personnel in Clinics" are also reported here.

Social Work in Medical Rehabilitation - A Review of Current Research

Quality assurance approaches by the German Statutory Pension Insurance emphasized the need of evidence-based practice for social work in medical rehabilitation. This study aims to show the state of research in rehabilitation science concerning social work and its effectiveness. The review is based on a literature search in 3 databases (Pubmed, Web of Sciences, Scopus) and a hand search in rehabilitation science journals and proceedings. 52 of 176 articles from 2000 to 2016 met the inclusion criteria. Social work is a common service in routine clinical practice with a substantial variation on the institutional level and between indications. Analysis of quality assurance data and observational studies showed negative as well as positive effects. The results indicate the need of an evidence-based practice of social work in medical rehabilitation.

Research on Participation in Working Life: On the Transfer from Theory into Practice

This study focuses on the theory-practice transfer in the field of research on participation in working life (LTA). The aim was to determine what expectations are prevalent on the part of service providers, how they access scientific knowledge, how the transfer into practice takes place and what research gaps exist. At the same time, representatives of the German Statutory Pension Insurance were asked about internal structures for identifying research topics and evaluating research results as well as for knowledge transfer. The aim of the article is to address the relationship between research and practice in the field of LTA and to create a sensitivity for this topic. The results of this study are based on a written survey of 28 Vocational Training Institutes (BFW) of the Federal Association of Vocational Rehabilitation Centres (BV BFW) and on three expert interviews with representatives of pension insurance companies (federal and regional). The response rate of the BFW survey was approximately 54% (N=15). For the evaluation of data primarily qualitative content analysis was applied, which included a step by step coding of the data. The results of the survey indicate a pronounced need for translation processes and a culture of cooperation between research and practice. At the same time, a tension between the preservation of the autonomy of research and an increasing transfer orientation became evident. In addition, a wide range of approaches for structuring possible transfer activities could be identified. In the area of research on services for participation in working life, the development of a strategy for research transfer represents a future task. It is necessary to explore new communication structures and participatory research formats in which research groups and sponsors as well as practitioners can jointly carry out research in this field.

Zusammenhang des Antrags- und Bewilligungsgeschehen in der psychosomatischen Rehabilitation mit der regionalen medizinischen und psychotherapeutischen Versorgung in Westfalen

Regional disparities in mental health care are well known and become apparent in inadequate treatment capacities and long waiting time for psychotherapeutic treatment. Hence, the authors assume that there is a shift from curative to rehabilitative care. Accordingly, the purpose of this study was to analyze the relationship between regional treatment capacities and the use of psychosomatic rehabilitation on behalf of the German Statutory Pension Insurance Westphalia (i. e. DRV Westfalen) in 2013. Regional data on medical and psychotherapeutic care within the purview of DRV Westfalen were drawn from public databases. Data on application and approval processes in psychosomatic rehabilitation as well as data on demographic and insurance-related traits, such as periods of insurance, were provided by DRV Westfalen for 2013. Logistic 2-level models were conducted. Regional data showed that poor medical care was associated with a significantly higher chance of applying for rehabilitation. The demographic and insurance-related traits of the applicants were significantly related both with the application for and approval of psychosomatic rehabilitation. Persons with a discontinuous work biography in 2013 had a higher chance for application for and approval of psychosomatic rehabilitation. No significant correlation of regional treatment capacities and the approval of applications for psychosomatic rehabilitation could be found. The results show that decisions on applications for psychosomatic rehabilitation basically depend on the personal health situation of the applicants. An increased application and approval rate in areas with poor medical care can be interpreted as compensatory means which indicate a need for improvement in regional care of mental disorders.

Return to work in heart failure patients with suspected viral myocarditis.

Background:Endomyocardial biopsy is considered as the gold standard in patients with suspected myocarditis. We aimed to evaluate the impact of bioptic findings on prediction of successful return to work.Methods:In 1153 patients (48.9 ± 12.4 years, 66.2% male), who were hospitalized due to symptoms of left heart failure between 2005 and 2012, an endomyocardial biopsy was performed. Routine clinical and laboratory data, sociodemographic parameters, and noninvasive and invasive cardiac variables including endomyocardial biopsy were registered. Data were linked with return to work data from the German statutory pension insurance program and analyzed by Cox regression.Results:A total of 220 patients had a complete data set of hospital and insurance information. Three quarters of patients were virus-positive (54.2% parvovirus B19, other or mixed infection 16.7%). Mean invasive left ventricular ejection fraction was 47.1% ± 18.6% (left ventricular ejection fraction <45% in 46.3%). Return to work was achieved after a mean interval of 168.8 ± 347.7 days in 220 patients (after 6, 12, and 24 months in 61.3%, 72.2%, and 76.4%). In multivariate regression analysis, only age (per 10 years, hazard ratio, 1.27; 95% confidence interval, 1.10–1.46; p = 0.001) and left ventricular ejection fraction (per 5% increase, hazard ratio, 1.07; 95% confidence interval, 1.03–1.12; p = 0.002) were associated with increased, elevated work intensity (heavy vs light, congestive heart failure, 0.58; 95% confidence interval, 0.34–0.99; p < 0.049) with decreased probability of return to work. None of the endomyocardial biopsy–derived parameters was significantly associated with return to work in the total group as well as in the subgroup of patients with biopsy-proven myocarditis.Conclusion:Added to established predictors, bioptic data demonstrated no additional impact for return to work probability. Thus, socio-medical evaluation of patients with suspected myocarditis furthermore remains an individually oriented process based primarily on clinical and functional parameters.

Satisfaction with rehabilitative health care services among German and non-German nationals residing in Germany: a cross-sectional study

ObjectivesRehabilitation following medical conditions is largely offered as in-patient service in Germany. Foreign-national residents use rehabilitative services less often than Germans and attain less favourable treatment outcomes. These differences are...

Was wäre, wenn wir Schweden wären? Ist das schwedische Rentensystem auf Deutschland übertragbar?

Abstract In regelmasigen Abstanden wird Schweden als Vorbild fur eine Reform der deutschen Rentenversicherung genannt. Hierbei werden meist die unterschiedlichen demographischen Ausgangssituationen beider Lander auser Acht gelassen. In dieser Studie wird die Bedeutung dieser Unterschiede fur die Ausgestaltungsmoglichkeiten der Rentenversicherungen beider Lander analysiert. Es zeigt sich, dass Schweden vor erheblich geringeren demographischen Herausforderungen steht. So wurde der Beitragssatz der GRV unter einer schwedischen Bevolkerung bis 2060 um 2,8 Prozentpunkte weniger stark ansteigen. Gleichzeitig ware das Brutto-Standardrentenniveau 2060 um 3,4 Prozentpunkte hoher. Umgekehrt wurde in Deutschland nach einer Umstellung auf das schwedische NDC-System mit konstantem Beitragssatz von 20 % die Absenkung des durchschnittlichen Brutto-Rentenniveaus im Vergleich zum derzeitigen System doppelt so hoch ausfallen. Dies ist vollstandig auf die unterschiedliche Verteilung der demographischen Last zwischen Rentner...

Disability Pension and Productivity Loss in Schizophrenia - An Empirical Analysis of the Financial Burden in Germany

Objective Quantification of the economic burden for society and the German Statutory Pension Insurance due to early retirement in schizophrenia. Methods Based on empirical data of the German Statutory Pension Insurance, productivity losses were calculated using the human capital approach. Results The total expenditures of the German Statutory Pension Insurance due to pension payments for schizophrenic insurants amounted to € 450 million. Total indirect costs due to morbidity and mortality were estimated at € 2,3 million. Average indirect costs per patient ranged between € 17 000 - 28 000, depending on rates for discounting and inflation. Conclusion Regarding substantial economic consequences, preventive measures and therapeutic procedures should aim to prevent reduction in earning capacity and to promote occupational reintegration of schizophrenic patients.

Effectiveness of Medical Rehabilitation on Return-to-Work Depends on the Interplay of Occupation Characteristics and Disease.

Introduction Work disability causes high costs for economy, organizations, and employees. However, medical rehabilitation does not always enable employees to return to their old jobs. In the present study, we investigated how disease classification and work characteristics interact in predicting the success of medical rehabilitation in terms of one's ability to return to a former job. Methods To this end, we matched 2009 patient data from the German Statutory Pension Insurance agency with job characteristics data from the Occupational Information Network (O*NET) 17.0 database. We used a multilevel approach and a sample of N=72,029, nested in 194 occupational groups. Results We found that workers are less likely to reenter a former job if mental illnesses coincide with emotionally demanding labor and if musculoskeletal diseases coincide with extreme environmental conditions. We did not find different effects between occupational groups for other types of diseases (circulatory system, neoplasms, injuries, others). Conclusion Thus, the contextual overlap of disease and occupational characteristics notably lowers the chances of a successful return-to-work. These findings should be taken into account by physicians when attempting to set realistic goals for rehabilitation in collaboration with the patient and the funding agency.

Rehabilitation Application Rejected - What Happens Then?

The German statutory pension insurance (Deutsche Rentenversicherung) rejects about a third of applications for medical rehabilitation. It is assumed that the health and occupational situation of people whose applications are rejected will become unsatisfactory. So far, there are no publications investigating the group of people with rejected applications. Of 2 075 included applicants, 345 persons were rejected. Patients whose applications were rejected were matched with those whose applications were approved (Propensity-Score-Matching). At the end of the study, evaluable data sets including all 3 time points of measurement (application, 4 and 10 months thereafter) were available for 173 applicants with rejected applications and for 223 applicants approved for rehabilitation. The course of development of both groups was analysed using variance analysis with repeated measurements. The study was conducted for 27 months (January 2012-March 2014). At the time of application, there were no differences in health and occupational situation between the 2 groups. Also, there were no differences between groups in their utilization of outpatient therapies in the year before their application. 4 months later, a small advantage for those with an approved application was observed, and occasionally there were even significant differences. Both groups used medical and other healthcare offers comparably frequently. 10 months after application, both groups showed further improvements. There were no differences in the number of physician or non-physician patient consultations. Our study could not confirm the assumption that the health or occupational situation of people with rejected application for rehabilitation suffers as a result of this rejection. Rather, the opposite seems to be the case. The factors that are responsible for the improvement, however, could not be identified by our study.

Cardiopulmonary exercise testing is predictive of return to work in cardiac patients after multicomponent rehabilitation.

Return to work (RTW) is a pivotal goal of cardiac rehabilitation (CR) in patients after acute cardiac event. We aimed to evaluate cardiopulmonary exercise testing (CPX) parameters as predictors for RTW at discharge after CR. We analyzed data from a registry of 489 working-age patients (51.5 ± 6.9 years, 87.9 % men) who had undergone inpatient CR predominantly after percutaneous coronary intervention (PCI 62.6 %), coronary artery bypass graft (CABG 17.2 %), or heart valve replacement (9.0 %). Sociodemographic and clinical parameters, noninvasive cardiac diagnostic (2D echo, exercise ECG, 6MWT) and psychodiagnostic screening data, as well as CPX findings, were merged with RTW data from the German statutory pension insurance program and analyzed for prognostic ability. During a mean follow-up of 26.5 ± 11.9 months, 373 (76.3 %) patients returned to work, 116 (23.7 %) did not, and 60 (12.3 %) retired. After adjustment for covariates, elective CABG (HR 0.68, 95 % CI 0.47-0.98; p = 0.036) and work intensity (per level HR 0.83, 95 % CI 0.73-0.93; p = 0.002) were negatively associated with the probability of RTW. Exercise capacity in CPX (in Watts) and the VE/VCO2-slope had independent prognostic significance for RTW. A higher work load increased (HR 1.17, 95 % CI 1.02-1.35; p = 0.028) the probability of RTW, while a higher VE/VCO2 slope decreased (HR 0.85, 95 % CI 0.76-0.96; p = 0.009) it. CPX also had prognostic value for retirement: the likelihood of retirement decreased with increasing exercise capacity (HR 0.50, 95 % CI 0.30-0.82; p = 0.006). CPX is a valid tool for assessing patients' ability to return to work. Therefore, it may be an essential part of functional assessment during CR for predicting participation in employment.

Risk Factors for Disability Pensioning Caused by Mental Disorders - A Systematic Review

Background: Meanwhile, mental disorders are the main reason for receiving a disability pension. The present study aimed at providing an overview of the German literature on characteristics and factors related to ERMD and pointing out the current state in this field of research. Revealing parameters that are accompanied by an ERMD is a precondition to prospectively prevent this trend. Methods: A systematic literature review was conducted from 2001 through to 2014. All results regarding German statutory pension insurants pensioned due to mental disorders after 2001 were included. Studies were considered if they reported 2 or more relevant results. Research design was not limited, except for excluding anonymous questionnaires. Results: 20 studies were found meeting eligibility criteria. All included studies were based on secondary analyses of data derived from the German statutory pension insurance. By means of gender-specific regression analyses the level of qualification and the geographical region were unveiled to be significant predictors of the ERMD. Basically, most reported results were descriptive or explorative. Besides various single results and evidence for interactions, frequently reported results are that: (i) female insurants get pensioned more frequently due to mental disorders than male insurants, (ii) affective disorders are the most frequent diagnoses, (iii) insurants with mental disorders are younger than insurants with somatic disorders when they get pensioned and (iv) insurants with schizophrenic disorders are younger than insurants with other mental disorders when they get pensioned. The utilisation of rehabilitative services before getting pensioned is limited at 50%. Conclusion: This work demonstrates a lack of empirical evidence of how (and what) disability risks are associated with ERMD in Germany. Furthermore, our results illustrate that a major part of the insurants do not attend rehabilitative services before their retirement, even though rehabilitation of mental illness is assumed to be effective. Future studies should hence focus on identifying disability related risk factors and barriers to using rehabilitative services in order to develop starting points for preventive and individual strategies.