Factors associated with general practitioners' contacts with sick-listed patients' employers: A Swedish nationwide questionnaire study.

Background: General practitioners' (GP) contacts with sick-listed patients' employers have been shown to be of importance for return to work. This study aimed to explore GPs' contacts with sick-listed patients' employers and factors associated with such contacts. Methods: In this cross-sectional study, 4228 GPs responded to a nationwide questionnaire about sickness certification (SC) practices. Outcomes of interest were participation in stakeholder meetings, having other contacts with employers, and satisfaction with employer contacts. Logistic regression models were used to investigate associations with factors related to the GP and the GP's workplace. Results: Among GPs, 34.8% participated in stakeholder meetings and 15.1% had other employer contacts; 39.4% had any or both of these contacts. Of GPs who had contacts with patients' employers, 65.8% were satisfied with the contacts. GPs regularly collaborating with rehabilitation coordinators had the strongest adjusted odds ratio (OR) for participating in stakeholder meetings, OR 2.72 (95% confidence interval (CI) 2.24-3.31), and having other contacts with employers, OR 3.85 (95% CI 2.85-5.21). Other factors positively associated with employer contacts were being a specialist, collaborating with other health professionals, finding employer contacts valuable, and having a joint SC routine/policy at the clinic. GPs who did not find SC problematic, had managerial support, or had enough resources for SC tasks were more likely to be satisfied with their employer contacts. Conclusions: Both physician characteristics and organizational factors had importance for GPs' contacts with sick-listed patients' employers. The findings imply that GPs' collaboration with patients' employers may be improved by interventions targeting both individual and organizational factors.

The concept of disease in the Norwegian National Insurance Court.

AIMS: The National Insurance Act administrates an important part of the welfare system in Norway by entitlements to benefits. Disease is an absolute requirement for many benefits, but the Act does not provide any definition of disease. The National Insurance Court is the normative body in management of the Act. In 1994, a consensus report was written on the concept of disease on behalf of the National Insurance Court, which subsequently became a guideline in the management of decisions. This study examined how the concept of disease has been interpretated in recent decisions in the National Insurance Court compared to the interpretation in the consensus report. METHODS: The material consisted of anonymous decisions from the National Insurance Court in the period from September 2018 to August 2019. It was analysed by systematic text condensation and compared to the consensus report by a theory-driven content analysis. RESULTS: The consensus report described disease as a value-laden condition with personal resources and external environment as decisive context, while the decisions express disease as a process with causal relationship to personal resources and external environment. CONCLUSIONS: The analysis of recent decisions showed that the interpretation of the concept of disease has moved in a value-neutral direction compared to the consensus report.

Occupational health patients' parallel use of primary- and secondary-care services and linkage to work disability: A follow-up study in Finland.

AIMS: This study aimed to investigate occupational health (OH) primary-care patients' use of other health-care services and whether parallel use affects their likelihood to have sickness absences (SA) or disability pensions (DP). METHODS: Primary-care services in Finland are provided through three parallel health-care sectors, all available to the working population: public, private and OH sectors. Patients may also be referred to secondary care. This follow-up study combines real-world medical record data containing SA data from a nationwide OH provider with health-care attendance data from public and private primary-care sectors and public secondary care, sociodemographic data and DP decisions. Patients between 18 and 68 years of age who used OH primary care at least once during the study years 2014-2016 were included. The total study population comprised 59,650 patients. Odds ratios were used to analyse association between parallel service use and SA or DP. RESULTS: Females and patients with a lower educational level were more likely to use services in other health-care sectors in addition to OH than others. Those patients who used any other health-care sector in addition to OH primary care had an increased likelihood of having long SA or receiving DP. CONCLUSIONS: OH primary-care patients using the services of several health-care sectors in parallel have an increased likelihood of receiving disability benefits - either SA or DP. There is need for care coordination to ensure adequate measures for work-ability support.

What is the effect of independent medical evaluation on days on sickness benefits for long-term sick listed employees in Norway? A pragmatic randomised controlled trial, the NIME-trial.

BACKGROUND: Independent medical evaluations are used to evaluate degree and reason for work disability, uncertainty around the functional status, and/or the employee's rehabilitation potential in several jurisdictions, but not in Norway. The main aim of this trial was to test the return to work effect of independent medical evaluation (IME) (summoning and consultation) compared to treatment as usual (TAU) in Norway, for workers who have been on continuous sick leave for 6 months. METHODS: This was a pragmatic randomised controlled trial including all employees aged 18-65 years, sick-listed by their general practitioner and on full or partial sick leave for the past 26 weeks in Hordaland County, Norway in 2015/16. Trial candidates were drawn from a central register at the Norwegian Labour and Welfare Administration at 22 weeks of sick leave. Pregnant women, individuals with cancer or dementia diagnoses, those with secret address, employed by NAV or sick listed by the specialist health services were excluded. Separate regression analyses were conducted to investigate the "intention-to-treat" and "treatment on the treated" effects, using the ordinary least squares and instrumental variable methods, respectively. RESULTS: After exemption based on predefined exclusion criteria, 5888 individuals were randomised to either IME (n = 2616) or TAU (n = 2599). The final intervention group constitutes 1698 individuals, of which 937 attended the IME consultation. No baseline differences were found between the IME and TAU group regarding gender, age, and previous sick leave. Individuals attending the IME were older than those who cancelled the appointment ((47/45), p = 0.006) and those who did not show up without cancelling ((47/42), p < 0.001). Mainly the IME physician agreed with the regular GP upon level of sick leave. In cases with different assessments, the difference tended to be towards a lower sick leave level. There were no intention to treat or treatment on the treated effect on days of sick leave after randomisation during follow up. CONCLUSIONS: Overall, the analyses showed no effect of IME on changes in sick leave for sick listed employees. This result was consistent for those who were offered an IME consultation (intention to treat) and those who undertook an IME consultation (treatment on the treated). TRIAL REGISTRATION: ClinicalTirals.gov trial number NCT02524392 first registration 14.08.2015.

Interventions regarding physicians' sickness certification practice - a systematic literature review with meta-analyses.

OBJECTIVE: A variety of interventions aiming to influence physicians' sickness certification practice have been conducted, most are, however, not evaluated scientifically. The aim of this systematic literature review was to obtain updated knowledge about interventions regarding physicians' sickness certification practice and to summarize their possible effects, in terms of sickness absence (SA) or return to work (RTW) among patients. METHODS: We searched PubMed and Web of Science up through 15 June 2020 and selected peer-reviewed studies that reported effects of controlled interventions that aimed to improve physicians' sickness certification practice and used SA or RTW among patients as outcome measures. Meta-analyses were conducted using random-effect models. RESULTS: Of the 1399 identified publications, 12 studies covering 9 interventions were assessed as relevant and included in the review. Most (70%) were from the Netherlands, two had a controlled, and seven a randomized controlled study design. All interventions included some type of training of physicians, and two interventions also included IT-support. Regarding the outcomes of SA/RTW, 30 different effect measures were used. In the meta-analyses, no statistically significant effect in favor of the interventions was observed for having any RTW (i.e. first, partial, or full) nor full RTW. CONCLUSIONS: The individual studies showed that physicians' sickness certification practice might be influenced by interventions in both the intended and non-intended direction, however, no statistically significant effect was indicated by the meta-analysis. The included studies varied considerably concerning intervention content and effect measures.KEY POINTSThe knowledge is very limited regarding the content of interventions directed to physician's sickness certification practiceThe identified interventions included some type of training of physicians, and some of them also included IT-support for physiciansThere was a great heterogeneity among the interventions concerning effect measures used regarding return to work among patientsThe individual studies showed that physicians' sickness certification practice might be influenced by interventions in both intended and non-intended directions, however, the overall meta-analysis did not indicate an effect.

The assessment of capacity limitations in psychiatric work disability evaluations by the social functioning scale Mini-ICF-APP.

OBJECTIVE: Insurers frequently commission medical experts to estimate the degree of the remaining work capacity (RWC) in claimants for disability benefits. The social functioning scale Mini-ICF-APP allows for a rating of activity and participation limitations in thirteen capacity domains, considered as particularly relevant for work ability. The current study sought to evaluate the role of the Mini-ICF-APP ratings in psychiatric work disability evaluations, by examining how the capacity limitation ratings varied with the claimants' primary psychiatric diagnoses and how the ratings were related to RWC estimates. METHODS: Medical experts estimated the RWC of 946 claimants with mental disorders and rated their activity and participation limitations using the Mini-ICF-APP, with higher ratings reflecting more severe limitations. The ratings were compared between claimants with different psychiatric diagnoses by analyses of variance. The mean Mini-ICF-APP rating across all capacity domains as well as all capacity-specific ratings were entered in simple or multiple regression models to predict the RWC in an alternative job. RESULTS: The Mini-ICF-APP capacity limitation ratings in all domains but mobility were higher for claimants with personality and behavior disorders as compared to those with mood disorders or with neurotic, stress-related and somatoform disorders. The largest differences were observed in social capacities (e.g. group integration: F 2, 847 = 78.300, P < 0.001). In claimants with depression, all ratings increased with the severity of the diagnosis (all Fs 2, 203 > 16.393, all Ps < 0.001). In the overall sample, the mean Mini-ICF-APP rating showed a strong negative correlation with the estimated RWC (r = -.720, P < 0.001). Adding the capacity-specific ratings to the prediction model improved this prediction only marginally. DISCUSSION: The Mini-ICF-APP allows for documenting claimants' activity and participation limitations, which is likely to increase the transparency of medical experts' RWC estimates and enables them to check the plausibility of such estimates. However, our study showed that despite the strong association between RWC and Mini-ICF-APP ratings, half of the RWC variance was unrelated to the capacity limitations documented in the Mini-ICF-APP.

Factors of decisive importance for being in work or not during two years after breast cancer surgery: content analysis of 462 women's open answers.

BACKGROUND: Paid work is one of the most important aspects in life among working-aged women diagnosed with breast cancer. Despite several attempts, no previous study provides a comprehensive overview from the women's perspective about factors of importance for being able to work or not. Therefore, the aim of this study was to gain knowledge about factors that women themselves state are of decisive importance for being able to work or not during the first two years after breast cancer surgery. METHODS: Data was collected in a two-year follow-up questionnaire within the frame of a prospective cohort study of working-aged women who had undergone breast cancer surgery. 749 were included in the questionnaire study and of the 616 (82%) responding women, 462 (75%) wrote statements on an open-ended question about factors of decisive importance for being able to work or not work during the past two years. The statements were analyzed with content analysis. RESULTS: Five categories of factors of importance for being able to  work or not were identified, each covering several sub-categories: Health and wellbeing, Contacts and encounters, Flexibility and adjustment possibilities, Socioeconomic consequences from working/not working, and Own motivation and characteristics. A wide variety of factors were mentioned by the women and the findings give a multifaceted picture of many single but interrelated factors of decisive importance for being able to work/not work. The importance of flexibility in the return-to-work process was stressed, as well as the importance of supportive encounters from, e.g., colleagues, managers, as well as relatives. CONCLUSIONS: The results give a comprehensive overview over a variety of different types of factors for being able to return to/remain in work or to not work after breast cancer surgery, adding new knowledge about e.g. the importance of colleagues, and the women's own preferences or characteristics. These are factors that different stakeholders, both from healthcare but also from the work place and the insurance office, need to be aware of and collaborate around to support women with breast cancer during the period of treatment, rehabilitation and return to work.

Exploring the concept inability to work fulltime in the context of work disability assessments: a qualitative study.

BACKGROUND: In many countries inability to work fulltime is recognized as an important concept in work disability assessments. However, consensus is lacking regarding the concept and how it should be assessed. This study seeks to conceptualize and operationalize the concept of inability to work fulltime, and includes perspectives of both patients and physicians. Research questions involve identifying: 1. key elements, 2. measurable indicators, and 3. valid methods for assessing indicators of inability to work fulltime. METHODS: We used a qualitative study with a thematic content analysis design to conceptualize inability to work fulltime, based on nineteen semi-structured interviews conducted among insurance and occupational health physicians, and representatives of patient organizations. RESULTS: Inability to work fulltime is conceptualized as a complex concept which is strongly individually determined and variable due to time and underlying disease. Key dimensions of inability to work fulltime included besides the disease itself, also personal factors like psychological and lifestyle factors, as well as environmental factors related to the work situation and social context. Fatigue, cognitive impairments, and restrictions in functioning in- and outside work were reported as important measurable indicators. A combined use of self-assessment, assessment interviews, and testing, and assessment in the actual (work) setting was identified for assessing these indicators. CONCLUSION: Taking into account the complex and variable nature of inability to work fulltime, we found it advisable to use multiple methods and multiple time points for the assessment. Results of this study provide starting points for further research on the operationalization of inability to work fulltime in a work disability context.

Oncologists' experiences of and prerequisites for sickness certification tasks: A nationwide questionnaire study.

Oncologists frequently have sickness certification (SC) consultations, however, little is known about their experiences of such tasks. OBJECTIVE: To investigate oncologists' experiences of organisational prerequisites for SC tasks, and if lack of resources was related to experiencing SC as problematic. METHOD: Questionnaire data from 342 oncologists in Sweden were used for descriptive statistics and to calculate odds ratios (OR) with 95% confidence intervals (CI). RESULTS: The majority (92.2%) had SC consultations weekly; 17.8% of the oncologists experienced such consultations as problematic weekly. About a third appreciated the national guidelines for SC (34.5%) and had joint routines/policies regarding SC at their clinic (29.7%). Experiencing SC consultations as problematic was associated with stating not having enough resources for such work (OR 3.47; 95% CI 1.92-6.25). Lack of resources was associated with: experiencing lack of competence in insurance medicine (3.34; 1.92-5.82), conflicts with patients regarding SC (4.22; 1.96-9.07), finding it problematic to manage the two roles as medical expert and as the patient's treating physician (3.31; 2.04-5.34), or to assess work capacity (2.28; 1.46-3.56). CONCLUSION: Although oncologists often had SC tasks, most did not experience them as problematic weekly. However, lack of resources for SC tasks was associated with experiencing SC as problematic.

Sickness absence and disability pension among women with breast cancer: a population-based cohort study from Sweden.

BACKGROUND: Women's return to work after diagnosis of breast cancer (BC) is becoming more prevalent. However, register-based national investigation on sickness absence (SA) and disability pension (DP) in BC women is lacking. The aim of the study was to explore SA and DP before and after a first BC diagnosis and the possibility to predict new cancer-related SA by using disease-related and sociodemographic factors. METHODS: A longitudinal register study of the 3536 women in Sweden aged 19-64 with a first BC diagnosis in 2010 was conducted by linkage of five nationwide registers. Particularly, detailed information on SA and DP was obtained from the National Social Insurance Agency. Descriptive statistics on SA and DP 2 years before through 3 years after the BC diagnosis were performed. The risk of having a new SA spell due to BC or BC-related diagnoses was modeled using logistic regression. RESULTS: The proportion of women with SA increased during the year following the BC diagnosis date and declined over the next 2 years to proportions before diagnosis. At the time of BC diagnosis, half of the women began a new SA spell > 14 days with cancer, cancer-related, or mental diagnosis. Disease-related and sociodemographic factors including occupational sector, living area, age, cancer stage, educational level, and number of previous SA days showed statistical significance (p < 0.05) in predicting a new SA around BC diagnosis. By using these factors, it was possible to correctly predict 67% of the new SA spell. CONCLUSIONS: SA among women with BC was elevated mainly in the first year after diagnosis. New SA following BC diagnosis can accurately be predicted.

Sickness absence and disability pension among injured working-aged pedestrians - a population-based Swedish register study.

BACKGROUND: The knowledge is scarce about sickness absence (SA) and disability pension (DP) among pedestrians injured in a traffic-related accident, including falls. Thus, the aim was to explore the frequencies of types of accidents and injuries and their association with SA and DP among working-aged individuals. METHODS: A nationwide register-based study, including all individuals aged 16-64 and living in Sweden, who in 2010 had in- or specialized outpatient healthcare after a new traffic-related accident as a pedestrian. Information on age, sex, sociodemographics, SA, DP, type of accident, injury type, and injured body region was used. Frequencies of pedestrians with no SA or DP, with ongoing SA or full-time DP already at the time of the accident, and with a new SA spell >14 days in connection to the accident were analyzed. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for new SA were estimated by logistic regression. RESULTS: In total, 5576 pedestrians received healthcare due to a traffic-related accident (of which 75% were falls, with half of the falls related to snow and ice). At the time of the accident, 7.5% were already on SA and 10.8% on full-time DP, while 20% started a new SA spell. The most common types of injuries were fractures (45%) and external injuries (30%). The body region most frequently injured was the lower leg, ankle, foot, and other (in total 26%). Older individuals had a higher OR for new SA compared with younger (OR 1.91; 95% CI 1.44-2.53, for ages: 45-54 vs. 25-34). The injury type with the highest OR for new SA, compared with the reference group external injuries, was fractures (9.58; 7.39-12.43). The injured body region with the highest OR for new SA, compared with the reference group head, face, and neck, was lower leg, ankle, foot, and other (4.52; 2.78-7.36). CONCLUSIONS: In this explorative nationwide study of the working-aged pedestrians injured in traffic-related accidents including falls, one fifth started a new SA spell >14 days. Fractures, internal injuries, collisions with motor vehicle, and falls related to snow and ice had the strongest associations with new SA.

A follow-up of the introduction of a maximum entitlement period for receiving sickness benefits in Sweden: A nationwide register-based study.

In 2008, Sweden introduced a policy change to limit the number of days for sickness benefits (SB). This study aimed to elucidate the characteristics of those who reached the maximum entitlement period for receiving sickness benefits (MEPSB) and their future main source of income. Methods: All 5,309,759 individuals, aged 20-63 and residents of Sweden in 2009 were followed from July 2008 to July 2010 regarding SB-days and date of MEPSB and then categorised into three groups: I) no SB-days, II) ongoing SB-days, and III) MEPSB. Mean numbers of SB-days 2.5 years before and 2 years after the policy change and main source of income in 2011 were assessed. Associations between sociodemographic factors, occupation and paid work as main source of income were estimated by odds ratio (OR). Results: A total of 0.7% reached MEPSB in 2010. The mean numbers of SB-days before and after the policy change were higher in the MEPSB group than in the other two groups. In the MEPSB group, 14% had their main source of income from paid work in 2011; this was more common among women born in Sweden (OR = 1.29), people living with a partner and children (women OR = 1.29; men OR = 1.48), and those with occupations representing high educational levels. Conclusions: One out of seven individuals with MEPSB in 2010 had their main source of income from paid work in 2011, although they had a long-term SB before and after the policy change. Further research is warranted to address the long-term effects of this policy change.

Functional Capacity Evaluation Research: Report from the Fourth International Functional Capacity Evaluation Research Meeting.

Purpose To summarize progress of functional capacity evaluation (FCE) research based on the proceedings of the Fourth International FCE Research Conference held in Switzerland on September 21 and 22, 2018. Methods A scientific committee identified key issues in FCE research and developed the program including key note presentations, a call for abstracts, and round table discussions over 2 days. Highlights of the presentations and discussions are summarized in this article. Results Seventy-nine participants from 11 countries attended the conference where 10 keynote lectures and 21 abstracts were presented. There was also an open discussion regarding the need for an International FCE clinical practice guideline (CPG), methods for developing such a guideline, and practical next steps. Full program details and abstracts from this Fourth International FCE Research Conference are available from https://www.sar-reha.ch/interessengemeinschaften/ig-ergonomie.html . Conclusions Researchers and clinicians continue to increase the body of knowledge in the FCE field. A major finding of this conference is the diversity across the different FCE protocols and research groups as well as of the different uses of FCE across cultural and social economic systems. Next steps will include exploring the development of an international, interdisciplinary, evidence-based FCE clinical practice guideline by a committee formed at the conference.

Physicians' experiences with sickness absence certification in Finland.

Aims: The aim of this study was to explore Finnish physicians' perceptions of sickness absence (SA) certification. Methods: A questionnaire was sent to 50% of the physicians in Finland who provide care to working-age patients in a clinical practice setting. Of the 8867 physicians, 3089 responded. Physicians handling SA certification patients at least a few times per month were included (n = 2472). Results: At least a few times per month, 61% of all physicians perceived SA issues as problematic, 60% had experienced a lack of time in dealing with SA matters, 36% had disagreed with a patient on SA certification, and 36% had met a patient who wanted a SA certificate for reasons other than a disease or injury. Physicians were least worried about patients filing complaints (4%), exhibiting threatening behaviour (2%), or switching physicians for SA certification reasons (1%). A total of 60% of physicians had prescribed SA for a longer period than necessary because of long waiting times for further care/measures. Non-specialized physicians, general practitioners, and psychiatrists experienced problems more frequently than surgeons and occupational health physicians. Over 50% of the respondents had a fairly large or very large need to deepen their knowledge of social insurance matters. The need for national guidelines for all or some diseases was reported by 80% of the respondents. Conclusions: Many physicians perceive SA tasks as problematic and are unable to dedicate enough time to them. Shortcomings in physicians' sickness certification know-how, as well as obstacles in the healthcare and rehabilitation system, prolong the SA process. Attitudes towards the adoption of national guidelines on the duration of SA were positive.

Injured worker experiences of insurance claim processes and return to work: a national, cross-sectional study.

BACKGROUND: Insurance claims management practices may have a significant impact on the health and experiences of injured workers claiming in workers' compensation systems. There are few multi-jurisdictional studies of the way workers experience compensation processes, and limited data on the association between claims experience and return to work outcomes. This study sought to identify worker, claim and injury related factors associated with injured worker experiences of workers' compensation claims management processes, and to examine associations between claims experience and return to work. METHODS: A national, cross-sectional survey of injured workers involved in ten Australian workers' compensation schemes. A total of 10,946 workers completed a telephone survey at 6 to 24 months post claim acceptance. Predictors of positive or negative/neutral claims experience were examined using logistic regression. Associations between claims experience, return to work status and duration of time loss were examined using logistic regression. RESULTS: Nearly one-quarter (23.0%, n = 2515) of workers reported a negative or neutral claims experience. Injury type, jurisdiction of claim, and time to lodge claim were most strongly associated with claims experience. Having a positive claims experience was strongly associated with having returned to work after accounting for injury, worker, claim and employer factors. CONCLUSIONS: There is a strong positive association between worker experiences of the insurance claims process and self-reported return to work status. Revision and reform of workers' compensation claims management practices to enhance worker experience and the fairness of procedures may contribute to improved return to work outcomes.

An instrument for quality assurance in work capacity evaluation: development, evaluation, and inter-rater reliability.

BACKGROUND: Employees insured in pension insurance, who are incapable of working due to ill health, are entitled to a disability pension. To assess whether an individual meets the medical requirements to be considered as disabled, a work capacity evaluation is conducted. However, there are no official guidelines on how to perform an external quality assurance for this evaluation process. Furthermore, the quality of medical reports in the field of insurance medicine can vary substantially, and systematic evaluations are scarce. Reliability studies using peer review have repeatedly shown insufficient ability to distinguish between high, moderate and low quality. Considering literature recommendations, we developed an instrument to examine the quality of medical experts' reports. METHODS: The peer review manual developed contains six quality domains (formal structure, clarity, transparency, completeness, medical-scientific principles, and efficiency) comprising 22 items. In addition, a superordinate criterion (survey confirmability) rank the overall quality and usefulness of a report. This criterion evaluates problems of inner logic and reasoning. Development of the manual was assisted by experienced physicians in a pre-test. We examined the observable variance in peer judgements and reliability as the most important outcome criteria. To evaluate inter-rater reliability, 20 anonymous experts' reports detailing the work capacity evaluation were reviewed by 19 trained raters (peers). Percentage agreement and Kendall's W, a reliability measure of concordance between two or more peers, were calculated. A total of 325 reviews were conducted. RESULTS: Agreement of peer judgements with respect to the superordinate criterion ranged from 29.2 to 87.5%. Kendall's W for the quality domain items varied greatly, ranging from 0.09 to 0.88. With respect to the superordinate criterion, Kendall's W was 0.39, which indicates fair agreement. The results of the percentage agreement revealed systemic peer preferences for certain deficit scale categories. CONCLUSION: The superordinate criterion was not sufficiently reliable. However, in comparison to other reliability studies, this criterion showed an equivalent reliability value. This report aims to encourage further efforts to improve evaluation instruments. To reduce disagreement between peer judgments, we propose the revision of the peer review instrument and the development and implementation of a standardized rater training to improve reliability.

Synergistic effect between ischaemic heart disease and common mental disorders and the risk of premature exit from the labour market: a nationwide register based study from Sweden.

Aims: Common mental disorders i.e. depressive and anxiety disorders (CMD) are frequent comorbid conditions in individuals with ischaemic heart disease (IHD). Still, their effect on preterm exit from the labour market [i.e. disability pension (DP)] in individuals with IHD has to date not been scrutinized. The aim of this study was to investigate the separate and joint effect of IHD and CMD on the risk of DP for women and men of working age. Material and methods: This population-based cohort study included all non-pensioned 4 823 069 individuals, registered as living in Sweden 31 December 2004 and then 16-64 years of age. Individuals with IHD or CMD were identified through using data on sickness absence, prescribed medication or in- or specialized outpatient care in 2005. Crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) for being granted DP in 2006-10 were estimated by means of Cox proportional hazard regression. Results: In the fully adjusted models, HRs for DP were 2.84 (95% CI; 2.57-3.13) and 2.83 (2.66-3.01) in women and men with IHD, respectively. Hazard ratios for DP in women and men with CMD were 5.13 (5.03-5.24) and 6.08 (5.93-6.24). In women and men with both conditions, crude HRs for DP were 18.38 (15.01-22.50) and 25.58 (22.27-29.37). There was a significant synergistic effect between IHD and CMD in both sexes in the crude models, which disappeared in women after adjusting for socio-demographic variables, and in men after additionally adjusting for comorbid somatic disorders. Conclusion: A comorbid CMD worsens the prognosis of IHD in terms of early exit from the labour market. Processes leading to DP in individuals with IHD are multifactorial and may involve the presence of CMD as well as comorbidity with other somatic diseases.

Sickness absence following breast cancer surgery: a two-year follow-up cohort study.

RATIONALE AND AIM: Most women of working ages with limited breast cancer (BC) have returned to work within the first year after diagnosis. However, little is known about what is happening during this year regarding sickness absence and return to work. Also, the knowledge is very limited about the occurrence of part-time sickness absence after BC diagnosis. Therefore, the aim of this study was to describe occurrence, extent and length of SA during a two-year follow-up after BC surgery and to analyse the association between being SA and type of cancer treatment. METHODS: In this prospective cohort study, 497 women responded to questionnaires about different aspects of sickness absence at six occasions during two years after primary BC surgery (at baseline and after 4, 8, 12, 18 and 24 months). Treatment information was obtained from the National breast cancer register. Multinomial logistic regression was used to calculate odds ratios (OR) for likelihood of being sickness absent more than once. RESULTS: Two-thirds of the women were sickness absent at baseline; this proportion decreased, especially during the first eight months. At 24 months, 13% were sickness absent. Of all women, 27% never reported sickness absence and 14% were sickness absent at most of the six survey times. At eight months, many had shifted from full- to part-time sickness absence. Women with chemotherapy and/or advanced BC surgery had higher ORs for being sickness absent at most of the follow-ups. CONCLUSIONS: Most women returned to work within the first eight months after BC surgery and of those sickness absent after that, most had been part-time sickness absent. Thus, it is important to differentiate between part- and full-time sickness absence in future studies. Special attention should be paid to the impact of chemotherapy and type of surgery on the likelihood of being sickness absent.

Registered nurses' work with sick leave questions by telephone in primary health care.

AIMS AND OBJECTIVES: To describe registered nurses' work with sick leave questions by telephone. BACKGROUND: In Sweden, when a sick person needs to request a sickness certification, it is common to contact the primary healthcare centre. The main access to primary health care is by telephone, with a registered nurse answering the care seeker's questions, triaging and helping care seekers to the right level of care. Registered nurses' work with sick leave questions has not been studied, except for two qualitative interview studies. DESIGN: A descriptive cross-sectional study. METHODS: A questionnaire with 120 questions was distributed to 185 registered nurses in one county in central Sweden. Descriptive statistics were used for analysis. RESULTS: Response rate was 62% (n = 114). Registered nurses (n = 105) in this study talked weekly to persons on, or at risk, for sick leave. A large part (n = 78) felt they had a role in the care of persons on sick leave, consisting of booking appointments as well as acting as a pilot, advisor, caretaker and coordinator. For 74 of 114 registered nurses, it was problematic to handle the phone calls weekly. Measures were 'often' booking appointments with physicians (n = 67) and 'seldom' providing information on social insurance rules ('never' n = 51). The registered nurses expressed a great need for more education. CONCLUSION: Registered nurses in this study reported having a role in the care of persons on sick leave when handling sick leave questions by telephone. The telephone calls were problematic to handle, and the registered nurses expressed a great need for education and training in social insurance medicine. RELEVANCE TO CLINICAL PRACTICE: There is a need to educate and train registered nurses in social insurance medicine to provide high-quality nursing for patients on or at risk for sick leave.

Synergistic effect between back pain and common mental disorders and the risk of future disability pension: a nationwide study from Sweden.

BACKGROUND: The aim of this study was to analyse a possible synergistic effect between back pain and common mental disorders (CMDs) in relation to future disability pension (DP). METHOD: All 4,823,069 individuals aged 16-64 years, living in Sweden in December 2004, not pensioned in 2005 and without ongoing sickness absence at the turn of 2004/2005 formed the cohort of this register-based study. Hazard ratios (HRs) and 95% confidence intervals (CIs) for DP (2006-2010) were estimated. Exposure variables were back pain (M54) (sickness absence or inpatient or specialized outpatient care in 2005) and CMD (F40-F48) [sickness absence or inpatient or specialized outpatient care or antidepressants (N06a) in 2005]. RESULTS: HRs for DP were 4.03 (95% CI 3.87-4.21) and 3.86 (95% CI 3.68-4.04) in women and men with back pain. HRs for DP in women and men with CMD were 4.98 (95% CI 4.88-5.08) and 6.05 (95% CI 5.90-6.21). In women and men with both conditions, HRs for DP were 15.62 (95% CI 14.40-16.94) and 19.84 (95% CI 17.94-21.94). In women, synergy index, relative excess risk due to interaction, and attributable proportion were 1.24 (95% CI 1.13-1.36), 0.18 (95% CI 0.11-0.25), and 2.08 (95% CI 1.09-3.06). The corresponding figures for men were 1.45 (95% CI 1.29-1.62), 0.29 (95% CI 0.22-0.36), and 4.21 (95% CI 2.71-5.70). CONCLUSIONS: Co-morbidity of back pain and CMD is associated with a higher risk of DP than either individual condition, when added up, which has possible clinical implications to prevent further disability and exclusion from the labour market.