Sick-leave decisions for patients with severe subjective health complaints presenting in primary care: a cross-sectional study in Norway, Sweden, and Denmark.

OBJECTIVES: The primary objective of this study was to explore whether general practitioners (GPs) in Norway, Sweden, and Denmark make similar or different decisions regarding sick leave for patients with severe subjective health complaints (SHC). The secondary objective was to investigate if patient diagnoses, the reasons attributed for patient complaints, and GP demographics could explain variations in sick leave decisions. DESIGN: A cross-sectional study. METHOD: Video vignettes of GP consultations with nine different patients. SUBJECTS: 126 GPs in Norway, Sweden, and Denmark. SETTING: Primary care in Norway, Sweden, and Denmark. MAIN OUTCOME MEASURE: Sick leave decisions made by GPs. RESULTS: "Psychological" diagnoses in Sweden were related to lower odds ratio (OR) of granting sick leave than in Norway (OR = 0.07; 95% CI = 0.01-0.83) Assessments of patient health, the risk of deterioration, and their ability to work predicted sick leave decisions. Specialists in general medicine grant significantly fewer sick leaves than non-specialists. CONCLUSION: Sick-leave decisions made by GPs in the three countries were relatively similar. However, Swedish GPs were more reluctant to grant sick leave for patients with "psychological" diagnoses. Assessments regarding health-related factors were more important than diagnoses in sick-leave decisions. Specialist training may be of importance for sick-leave decisions.

Self-Reported Measures Have a Stronger Association With Dizziness-Related Handicap Compared With Physical Tests in Persons With Persistent Dizziness.

Background: Associations between dizziness-related handicap and a variety of self-reported measures have been reported. However, research regarding associations between dizziness-related handicap and aspects of functioning that includes both physical tests and self-reported measures is scarce. Objective: The purpose of the study was to describe the variations in signs and symptoms in people with persistent dizziness using physical tests and self-reported outcomes across three severity levels of the Dizziness Handicap Inventory (DHI) and investigate their associations with the DHI. Method: Participants with persistent dizziness (n = 107) were included in this cross-sectional study. The participants underwent (1) physical tests (gait tests, grip strength, body flexibility, and movement-induced dizziness) and completed questionnaires regarding (2) psychological measures (Mobility Inventory of Agoraphobia, Body Sensation Questionnaire, Agoraphobic Cognitions Questionnaire, and Hospital Depression and Anxiety Questionnaire), and (3) fatigue, dizziness severity, and quality of life (Chalders Fatigue Scale, Vertigo Symptom Scale-Short Form, and EQ visual analog scale), in addition to the DHI. Data were presented by descriptive statistics for three DHI severity levels (mild, moderate, and severe). A multiple linear backward regression analysis was conducted for each group of measures in relation to the DHI total score, with additional analyses adjusting for age and sex. Based on these results, significant associations were tested in a final regression model. Results: With increasing severity levels of DHI, the participants demonstrated worse performance on most of the physical tests (preferred and fast gait velocity, dizziness intensity after head movements), presented with worse scores on the self-reported measures (avoidance behavior, fear of bodily sensation, fear of fear itself, psychological distress, fatigue, dizziness severity, quality of life). After adjusting for age and sex, significant associations were found between total DHI and avoidance behavior, psychological distress, dizziness severity, and quality of life, but not with any of the physical tests, explaining almost 56% of the variance of the DHI total score. Conclusion: There was a trend toward worse scores on physical tests and self-reported measurements with increasing DHI severity level. The DHI seems to be a valuable tool in relation to several self-reported outcomes; however, several signs and symptoms may not be detected by the DHI, and thus, a combination of outcomes should be utilized when examining patients with persistent dizziness.

Why are general practitioners reluctant to enrol patients into a RCT on sick leave? A qualitative study.

AIMS: To explore the reluctance of, and examine the arguments given by Norwegian general practioners (GPs), regarding their unwillingness to recruit their patients for a study where sick leave would be based on randomization. METHODS: A qualitative study presenting individual arguments from 50 Norwegian GPs, as written responses to a web-based, open-ended questionnaire. The responses, ranging from 3-145 words, were analysed with systematic text condensation. RESULTS: The GPs did not want to participate in a study where sick leave was decided by randomization. First, the complexity of clinical judgment was addressed. Would it be ethically acceptable to set the professional and medical assessment aside, and if so, was there any better judge than the regular GP in making this important decision? Second, the arguments dealing with sick leave as a human and legal right were addressed. Will patients feel they have a legitimate right to sick leave and will they be open for discussion with their GP? Third, the risk of jeopardizing the relationship between patient and doctor was emphasized. Would the patients be able to trust their GP if he or she offered the patient entry into a trial where sick leave would be decided by randomization? CONCLUSIONS: Randomization of sick leave in general practice in Norway was not viewed as feasible by the GPs themselves because of the importance of clinical judgment, ethical obligations, and the belief that the patients would refuse participation, and thereby, that the doctor-patient relationship would be disturbed.

What facilitates return to work? Patients' experiences 3 years after occupational rehabilitation.

OBJECTIVE: We have limited knowledge about the specific elements in an occupational rehabilitation programme that facilitate the process leading to return to work (RTW) as perceived by the patients. The aim of the study was to explore individual experiences regarding contributing factors to a successful RTW, 3 years after a resident occupational rehabilitation programme. METHODS: The study is based on interviews of 20 individuals who attended an occupational rehabilitation programme 3 years earlier. Ten informants had returned to work (RTW) and ten were receiving disability pension (DP). Data were analysed by systematic text condensation inspired by Giorgi's phenomenological analysis. RESULTS: The core categories describing a successful RTW process included positive encounters, increased self-understanding and support from the surroundings. While the informants on DP emphasized being seen, heard and taken seriously by the professionals, the RTW group highlighted being challenged to increase self-understanding that promoted new acting in every-day life. Being challenged on self-understanding implied increased awareness of own identity, values and resources. Support from the surroundings included support from peer participants, employer and social welfare system. CONCLUSION: Successful RTW processes seem to comprise positive encounters, opportunities for increased self-understanding and support from significant others. An explicit focus on topics like identity, own values and resources might improve the outcome of the rehabilitation process.

Descriptions of movement experiences in the Body Awareness Rating Scale - Movement Quality and Experience evaluation. A qualitative study of patients diagnosed with hip osteoarthritis.

Background: Patients' access to movement experiences is implemented in the evaluation tool Body Awareness Rating Scale - Movement Quality and Experience, with its two intertwined parts: 1) the physiotherapist's observations of movement quality; and 2) the patient's descriptions of immediate movement experiences.Objective: To study movement experiences and reflections described by patients diagnosed with hip osteoarthritis when guided to explore simple daily-life movements in this particular evaluation context.Design: An explorative qualitative study with open-ended questions following each of the 12 movements integrated into the evaluation.Methods: 35 participants diagnosed with hip osteoarthritis were included; 28 women and 7 men, aged 23-78 years. Their descriptions were audiotaped, transcribed verbatim and analyzed in accordance with qualitative content analysis.Results: The patients described experiences of a dynamic adaptation of movement strategies based on sensations from the moving body. Two interrelated categories of movement awareness were identified: 1) Experienced movement challenges, including three sub-categories; a) Lack of contact, b) Movement changed by symptoms, and c) Compensational movement habits, and 2) Movement components promoting well-being, including three sub-categories; a) Integrating balance, breathing and awareness into movement, b) Small, simple, soft and safe movements, and c) A taste of own movement resources for daily life.Conclusions: The Body Awareness Rating Scale - Movement Quality and Experience provides a platform for patients to become aware of and describe their movement habits and resources in own words, intertwined with the physiotherapist movement observations. Derived descriptions reflect a patient perspective to be implemented in therapy.

Long-term follow-up of disability pensioners having musculoskeletal disorders.

BACKGROUND: Previously we have conducted a randomised controlled trial (RCT) to evaluate the effect of a brief cognitive behavioural program with a vocational approach aiming to return disability pensioners with back pain to work, as compared to no intervention. One year after the intervention, 10 participants (22%) who received the program and 5 (11%) in the control group reported to have entered a return to work process. The aims of this study were to evaluate long-term effects of the intervention, and compare this effect to 2 reference populations not participating in the original trial. METHODS: Three groups of disability pensioners were investigated: 1) Disability pensioners having back pain (n = 89) previously participating in the RCT (randomized to either a brief cognitive behavioural intervention or to a control group), 2) 342 disability pensioners having back pain, but refusing to participate in the study and 3) 449 disability pensioners having other musculoskeletal disorders than back pain. Primary outcome was return to work, defined as a reduction in payment of disability pension. RESULTS: Only 2 of 89 (2.3%) participants from the RCT had reduced disability pension at 3-years follow-up, both from the control group. None of the participants that had been in a process of returning to work after 1 year had actually gained employment at 3-years follow-up. In the 2 groups not participating in the previous RCT, only 4 (1.2%) and 8 (1.6%) had returned to work after 3 years respectively. CONCLUSION: The number of pensioners who returned to work was negligible in all groups regardless of having participated in a cognitive behavioural intervention or not.