General practitioners' use of sickness certification guidelines in Sweden at introduction and four years later: a survey study.

OBJECTIVE: National sickness certification guidelines were introduced in Sweden in 2007, comprising both overarching and diagnoses-specific recommendations. This study aimed to investigate how general practitioners (GP) used and perceived the usefulness of these guidelines in the sickness certification process close after introduction and 4 years later. DESIGN: Two nationwide cross-sectional surveys in 2008 and 2012. SETTING: Swedish healthcare. PARTICIPANTS: Physicians working in primary healthcare and having sickness certification consultations at least a few times per year (n = 4214 in 2008, and n = 4067 in 2012). MAIN OUTCOME MEASURES: Frequency of use and perceived usefulness of the sickness certification guidelines. RESULTS: Most GPs used the guidelines at least a few times per year (in 2008 74.6%; in 2012 85.2%). In 2008, 44.1% reported a need to develop competence in using the guidelines, compared with 23.3% in 2012. Of those using the guidelines, 36.7% in 2008 and 44.6% in 2012 reported it problematic to write sickness certificates in accordance with the guidelines. Most GPs (89.2% in 2008 and 88.8% in 2012) valued the guidelines beneficial to ensure quality in sickness certification consultations. A larger proportion in 2012 compared with 2008 reported that the guidelines facilitated contacts with patients (61.2%, respectively, 55.6%), as well as with other stakeholders. CONCLUSIONS: The guidelines were perceived as useful and beneficial to ensure high quality in sickness certification consultations, and facilitated contacts with patients as well as other stakeholders. In 2012, still one-fourth reported a need to develop more competence in using the sickness certification guidelines.

Occupational health physicians have better work conditions for handling sickness certification compared with general practitioners: results from a nationwide survey in Sweden.

AIMS: To study whether occupational health physicians (OPs) have a better work situation regarding handling of sickness certification compared with other physicians, in particular general practitioners (GPs), and to analyze associations between OPs' experiences of assessing and providing a long-term prognosis of patients' work capacity and some potentially interrelated factors. METHODS: Answers to a nationwide survey from physicians who had sickness certification consultations at least once monthly were analyzed. Differences among OPs (n=481), GPs (n=4257) and physicians working in other clinical settings (n=9452) were estimated by chi square tests. Associations between OPs' experiences as above and potentially interrelated factors were estimated using logistic regression analyses. RESULTS: Among OPs, a lower proportion experienced clinical work situations related to sickness certifications as 'very problematic', compared with the other physicians, and especially so compared with GPs. A higher proportion of OPs also had organizational support for handling sickness certifications. For OPs, experience of sickness certification consultations as problematic once a month or less often, not experiencing sickness certification tasks as a work environment problem, and having a well-established workplace policy regarding sickness certification matters were significantly positively associated with finding assessing and providing a long-term prognosis of work capacity as 'not at all/somewhat problematic'. CONCLUSIONS: OPs' work situation regarding sickness certifications was favorable compared with that of other physicians, and especially compared with that of GPS. Our results underline the importance of organizational support for ensuring physicians' experience of having professional competence in handling assessments of patients' work capacity.

Problems with sickness certification tasks: experiences from physicians in different clinical settings. A cross-sectional nationwide study in Sweden.

BACKGROUND: Many physicians find sickness certification of patients problematic. The aims were to explore problems that physicians in different clinical settings experience with sickness certification tasks in general and with assessment of function, work capacity, and need for sick leave, as well as handling of sick-leave spells of different durations. METHODS: Data from a questionnaire sent to 33,144 physicians aged <68 years, living and working in Sweden in 2012 were analysed. The response rate was 57.6%. The study group comprised the 12,933 responders who had sickness certification tasks. Frequencies and odds ratios with 95% confidence intervals were calculated for questions concerning how problematic the physicians experienced different assessments related to patients' function, work capacity, and need for sick leave, as well as handling sick-leave spells of different durations. RESULTS: There were large differences between clinical settings regarding how often and to what extent sickness certification consultations were perceived as problematic. Physicians working in primary health care (PHC) had the highest proportions experiencing sickness certification consultations as problematic at least once a week (49.5%) and as very or fairly problematic (56.6%), followed by physicians working in psychiatry, pain management, or orthopaedics. More than half of the responders found it very or fairly problematic to assess patients' work capacity (57.8%), to make a long-term prognosis about patients' future work capacity (55.7%), and to handle long-term or very long-term sickness certifications (51.9% and 51.8%). The proportions were highest among physicians working in PHC, rheumatology, neurology, or psychiatry. CONCLUSIONS: The rates of physicians finding sickness certification task problematic varied much with clinical setting, and were highest among physicians in PHC. More knowledge is needed about the work conditions and prerequisites for optimal handling of sickness certification in different clinical settings.

Problems experienced by gynecologists/obstetricians in sickness certification consultations.

OBJECTIVE: To explore frequencies and experiences with problems in sickness certification consultations among gynecologists and obstetricians in two different years. DESIGN: Cross-sectional surveys on two occasions; in 2004 and 2008. SETTING: Gynecological, obstetric and maternal health care. SAMPLE: Physicians working in gynecology, obstetrics or maternal health care in two Swedish counties from two samples: in 2004 (n = 315), and in 2008 (n = 327). METHODS: Data regarding sickness certification consultations were obtained from comprehensive questionnaires that had been mailed to the physicians in two Swedish counties in 2004 and in 2008, respectively. OUTCOME MEASURES: Frequencies and types of problems in sickness certification consultations, organizational support, and need to acquire more competence. RESULTS: The majority experienced that patients requested to be on sick leave for a reason other than work incapacity due to disease or injury, at least a few times per year (85% in 2004 and 88% in 2008). The most problematic situation to handle was when the physician and the patient had different opinions about the need for sick leave (2004: 66% and 2008: 58%). The physicians expressed a need for more competence about the options and responsibilities of employers, social insurance officers and physicians in sickness certification cases. CONCLUSIONS: Most gynecologists/obstetricians find sickness certification consultations problematic and especially when encountering patients requesting to be on sick leave for reasons other than disease. The physicians expressed a need for more competence in insurance medicine, especially about their own and other stakeholders' options and responsibilities.

Reasons for and factors associated with issuing sickness certificates for longer periods than necessary: results from a nationwide survey of physicians.

BACKGROUND: Physicians' work with sickness certifications is an understudied field. Physicians' experience of sickness certifying for longer periods than necessary has been previous reported. However, the extent and frequency of such sickness certification is largely unknown. The aims of this study were: a) to explore the frequency of sickness certifying for longer periods than necessary among physicians working in different clinical settings; b) to examine main reasons for issuing sickness certificates for longer periods than necessary; and c) to examine factors associated with unnecessary issued sickness certificates. METHODS: In 2008, all physicians living and working in Sweden (a total of 36,898) were sent an invitation to participate in a questionnaire study concerning their sick-listing practices. A total of 22,349 (60.6%) returned the questionnaire. In the current study, physicians reporting handling sickness certification consultations at least weekly were included in the analyses, a total of 12,348. RESULTS: The proportion of physicians reporting issuing sickness certificates for longer periods than actually necessary varied greatly between different types of clinics, with the highest frequency among those working at: occupational medicine, orthopedic, primary health care, and psychiatry clinics; and lowest among those working in: eye, dermatology, ear/nose/throat, oncology, surgery, and infection clinics. Logistic analyses showed that sickness certifying for longer periods than necessary due to limitations in the health care system was particularly common among physicians working at occupational medicine, orthopedic, and primary health care clinics. Sickness certifying for longer periods than necessary due to patient-related factors was much more common among physicians working at psychiatric clinics. In addition to differences between clinics, frequency of sickness certificates issued for longer periods than necessary varied by age, physicians' experiences of different situations, and perceived problems. CONCLUSIONS: This study showed that physicians issued sickness certificates for longer periods than actually necessary quite frequently at some types of clinics. Differences between clinics were to a large extent associated with frequency of problems, lack of time, delicate interactions with patients, and need for more competence.

Psychiatrists' work with sickness certification: frequency, experiences and severity of the certification tasks in a national survey in Sweden.

BACKGROUND: Many psychiatrists are involved in sickness certification of their patients; however, there is very limited knowledge about this aspect of their work. The objective of this study was to explore frequencies of problematic issues in the sickness certification tasks and experiences of severity regarding these problematic issues among psychiatrists. METHODS: A cross-sectional nationwide questionnaire study to all physicians in Sweden. The 579 specialists in psychiatry who answered the questionnaire, were under 65 years of age, worked mainly in psychiatric care, and had consultations involving sickness certification at least once a week were included. RESULTS: The frequency of problematic sickness certification consultations a few times per year or more often was considered by 87.3% of the psychiatrists; 11.7% handle such cases at least once a week. A majority (60.9%) reported 'not having enough time with the patient' at least once a week. The psychiatrists had access to several categories of professionals in their daily work. More than one third certified unnecessarily long sick-leave periods at least once a month due to waiting times for Social Insurance Office investigations or for treatments or investigations within health care. CONCLUSION: The majority found it problematic to assess the level and duration of work incapacity, but also other types of problems like unnecessarily long sick-leave periods due to different types of waiting times. The findings have implications for different kinds of organisational and managerial support and training in sickness certification issues, like guidance to assess the level and duration of work incapacity.

Aerobic fitness in patients at work despite recurrent low back pain: a cross-sectional study with healthy age- and gender-matched controls.

OBJECTIVE: The aims of this study were to compare the aerobic fitness level of working patients who have recurrent low back pain with those of healthy age- and gender-matched controls, and to investigate the relationship of aerobic fitness level with pain intensity, general health, perceived disability, fear-avoidance beliefs and self-efficacy. SUBJECTS AND METHODS: A total of 57 patients with recurrent low back pain, with a mean of 10 years' pain duration and 57 healthy controls performed a sub-maximal Astrand cycle test. Predicted maximum oxygen consumption was calculated and compared. Correlations between the low back pain patients' predicted aerobic fitness level and the assessed variables were calculated. RESULTS: The women with low back pain had lower predicted aerobic fitness levels than the healthy women (p<0.05). For the men there was no such difference. Multiple regression analysis showed that age, gender, body mass index and self-efficacy were associated with the predicted aerobic fitness level. CONCLUSION: This study suggests no overall difference in predicted aerobic fitness level for a sample of subjects with recurrent low back pain compared with healthy controls. This is perhaps because all the patients were still at work despite the pain. The results indicate, however, that the factors associated with aerobic fitness differ between men and women.

Obstetricians/Gynecologists' Problems in Sickness Certification Consultations: Two Nationwide Surveys.

Objective. To explore experiences by physicians working in obstetrics, gynecology, or maternal healthcare (O/Gs) of problems in sickness certification consultations and differences between two years. Material and Methods. Answers by O/Gs to two Swedish nationwide surveys, in 2008 (n = 1037) and 2012 (n = 992), were analyzed for frequencies and severity of problems and organizational support in sickness certification consultations. Results. One-third of O/Gs found sickness certifications problematic every week. The most frequent problem was patients requesting sick notes for reasons other than work incapacity due to disease/injury (2008: 21%; 2012: 16%). The most problematic were assessing work capacity (2008 and 2012: 52%) and having different opinion from that of the patient about need for sick leave (2008: 51%; 2012: 46%). In 2012, 27% used the national sickness certification guidelines weekly, compared to 9% in 2008. A larger proportion in 2012 than 2008 reported that the guidelines facilitated contacts with patients and different stakeholders. Conclusions. Although O/Gs perceived sickness certification as problematic, there was less perceived severity of problems in 2012 compared to 2008, possibly because interventions regarding sickness certification have been introduced in Sweden recent years. Still, more organizational support, for example, time and supervision, are needed to enhance O/Gs' sickness certification practices.

A 3-year follow-up of a multidisciplinary rehabilitation programme for back and neck pain.

The aim of the present study was to evaluate the long-term outcome of a behavioural medicine rehabilitation programme and the outcome of its two main components, compared to a 'treatment-as-usual' control group. The study employed a 4 x 5 repeated-measures design with four groups and five assessment periods during a 3-year follow-up. The group studied consisted of blue-collar and service/care workers on sick leave, identified in a nationwide health insurance scheme in Sweden. After inclusion, the subjects were randomised to one of the four conditions: behaviour-oriented physiotherapy (PT), cognitive behavioural therapy (CBT), behavioural medicine rehabilitation consisting of PT+CBT (BM) and a 'treatment-as-usual' control group (CG). Outcome variables were sick leave, early retirement and health-related quality of life. A cost-effectiveness analysis, comparing the programmes, was made. The results showed, consistently, the full-time behavioural medicine programme being superior to the three other conditions. The strongest effect was found on females. Regarding sick leave, the mean difference in the per-protocol analysis between the BM programme and the control group was 201 days, thus reducing sick leave by about two-thirds of a working year. Rehabilitating women has a substantial impact on costs for production losses, whereas rehabilitating men seem to be effortless with no significant effect on either health or costs. In conclusion, a full-time behavioural medicine programme is a cost-effective method for improving health and increasing return to work in women working in blue-collar or service/care occupations and suffering from back/neck pain.

Physical performance tests for people with long-term spinal pain: aspects of construct validity.

OBJECTIVE: The aim of this study was to investigate the construct validity of 6 physical performance tests that had already been shown to have acceptable repeatability. DESIGN: Data were collected in a randomized controlled multi-centre study. SUBJECTS: 126 women and 105 men sick-listed for spinal pain carried out the tests and provided personal and background data at inclusion in the study. METHODS: One test measured stepping up onto and down from a stool, 2 measured lifting ability and 3 walking speed. Construct validity was examined by analysing the influence of some variables on test performance. RESULTS: High-rated pain behaviour and perceived high pain intensity during testing or during the previous 4 weeks were connected with low test performance. Exercise twice a week was connected with high test performance. The test with the highest ability to detect disability in the women with lumbar pain was a lumbar lifting test, while for the men, it was a cervical lifting test. The test with the highest ability to detect disability in the participants with neck pain was the cervical lifting test in addition to a gait test with burden for the women. CONCLUSION: Back pain hampered the test performance more than neck pain. Impairments and activity limitations expressed by the patient should guide the choice of test.

Physical performance tests for people with spinal pain--sensitivity to change.

OBJECTIVE: The sensitivity to change for six physical performance tests for assessing impairments and activity limitations in persons with spinal pain was examined. METHOD: Eighty men and 106 women with long-term spinal pain participating in a randomized controlled study went through the tests on inclusion in the study, and were then invited to follow-up tests after 5 weeks and 6 months. The tests were a 'step-on-stool test', three gait tests and two lifting tests (PILE tests). Sensitivity to change was examined by relating changes in physical performance to self-rated concepts assumed to reflect a real change in the individual. Effect sizes were calculated. RESULT: Sensitivity to change in absolute values was revealed for the gait test with burden, the stair-climbing test and the PILE cervical test for women. Only the PILE cervical test showed responsiveness to clinically important change according to our criteria. Moderate to high effect sizes were found for all tests. Relatively few subjects improved to an extent considered clinically important. Improvement was greater in subjects whom inclusion measurements showed to be less fit. CONCLUSIONS: The sensitivity to change was moderate over a 6-month period for the physical performance tests. The gait test with burden, the stair-climbing test and the PILE tests were most sensitive to change. It is suggested that these tests be incorporated in an 'assessment instrument bank' for physiotherapists, supplemented with other reliable and valid tests relevant to the problems for the individual with spinal pain.

Physicians who experience sickness certification as a work environmental problem: where do they work and what specific problems do they have? A nationwide survey in Sweden.

OBJECTIVES: In a recent study, 11% of the Swedish physicians below 65 years dealing with sickness certification tasks (SCT) experienced SCT to a great extent as a work environment problem (WEP). This study aimed at exploring which SCT problems those physicians experienced and if these problems varied between general practitioners (GPs), psychiatrists, orthopaedists and physicians working at other types of clinics. DESIGN: A cross-sectional nationwide questionnaire study. SETTING: All physicians working in Sweden in 2008. PARTICIPANTS: The 1554 physicians <65 years old, working in a clinical setting, having SCT and stating SCT to a great extent being a WEP. OUTCOME MEASURES: Frequency of possibly problematic situations or lack of time, reasons for sickness certifying unnecessarily long, experience of difficulties in contacts with sickness insurance offices, and severity of experienced problems. RESULTS: In all, 79% of this group of physicians experienced SCT as problematic at least once weekly, significantly higher proportion among GPs (p<0.001) and psychiatrists (p=0.005). A majority (at most 68.3%) experienced lack of time daily, when handling SCT, the proportion being significantly higher among orthopaedists (p=0.003, 0.007 and 0.011 on three respective items about lack of time). Among psychiatrists, a significantly higher proportion (p<0.001) stated wanting a patient coordinator. Also, GPs agreed to a higher extent (p<0.001) to finding 14 different SCT tasks as 'very problematic'. CONCLUSIONS: The main problem among physicians who experience SCT to a great extent as a WEP was lack of time related to SCT. The proportion of physicians experiencing problems varied in many aspects significantly between the different work clinics; however, GPs were among the highest in most types of problems. The results indicate that measures for improving physicians' sickness certification practices should be focused on organisational as well as professional level and that the needs in these aspects differ between specialties.