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.

Psychosocial work factors and sick leave, occupational accident, and disability pension: a cohort study of civil servants.

OBJECTIVE: To study associations between psychosocial work factors (PWF) and sick leave, occupational accident, and disability pension. METHODS: A random population of 967 civil servants participated in a survey on PWF and health. The median follow-up time was 7 years. RESULTS: Frequent feedback from supervisor, good opportunities for mental growth, good team climate, and high appreciation were associated with a decrease in the risk of sickness absences and shift/period work, monotonous movements, and crowdedness of workplace were associated with an increase in the risk of sickness absences. Good communication at work was associated with a decrease in client violence and high work pressure was associated with an increased risk of occupational accidents. High work control and good team climate were associated with a decreased and shift/period work and client violence was associated with an increased risk of disability pensions. CONCLUSIONS: Psychosocial work factors can predict health outcomes with economic impact.

Factors associated with the utilization and costs of health and social services in frail elderly patients.

BACKGROUND: Universal access is one of the major aims in public health and social care. Services should be provided on the basis of individual needs. However, municipal autonomy and the fragmentation of services may jeopardize universal access and lead to variation between municipalities in the delivery of services. This paper aims to identify patient-level characteristics and municipality-level service patterns that may have an influence on the use and costs of health and social services of frail elderly patients. METHODS: Hierarchical analysis was applied to estimate the effects of patient and municipality-level variables on services utilization. RESULTS: The variation in the use of health care services was entirely due to patient-related variables, whereas in the social services, 9% of the variation was explained by the municipality-level and 91% by the patient-level characteristics. Health-related quality of life explained a major part of variation in the costs of health care services. Those who had reported improvement in their health status during the preceding year were more frequent users of social care services. Low informal support, poor functional status and poor instrumental activities of daily living, living at a residential home, and living alone were associated with higher social services expenditure. CONCLUSIONS: The results of this study showed municipality-level variation in the utilization of social services, whereas health care services provided for frail elderly people seem to be highly equitable across municipalities. Another important finding was that the utilization of social and health services were connected. Those who reported improvement in their health status during the preceding year were more frequently also using social services. This result suggests that if municipalities continue to limit the provision of support services only for those who are in the highest need, this saving in the social sector may, in the long run, result in increased costs of health care.

Employee and work-related predictors for entering rehabilitation: a cohort study of civil servants.

OBJECTIVE: The aim of this study was to determine how employee well-being, psychosocial factors at work, leadership and perceived occupational health services predict entering rehabilitation as modelled in the Job Well-being Pyramid. METHODS: A random population of 967 civil servants participated in a survey on psychosocial factors and health at work in 2000 in Finland. A total of 147 employees entered rehabilitation during the median follow-up time of 7 years. RESULTS: Permanent employment, large organizations, feedback from supervisors, client violence and physically monotonous work were associated with an increased rate of entering rehabilitation, whereas physical jobs, clear aims, high appreciation, job satisfaction and job enjoyment were associated with a decreased rate of entering rehabilitation. Employee well-being in general was also associated with entering rehabilitation, and this was decreased by good work ability, good health, mental well-being and physical fitness and increased by constant musculoskeletal symptoms. On the other hand, support from supervisors, job control, work pressure, team climate at work, communication, bullying and discrimination, physical work environment, and sense of coherence appeared to have no association. CONCLUSION: Various psychosocial factors at work and job well-being predict entering rehabilitation. The association between employee health and entering rehabilitation refers to the fact that the selection process for rehabilitation works reasonably well and those in need of rehabilitation are also granted it. In general, these findings coincide well with the Job Well-being Pyramid model. Improving job conditions and well-being at work is likely to decrease the need for rehabilitation.

Employee well-being and sick leave, occupational accident, and disability pension: a cohort study of civil servants.

OBJECTIVE: To study the association between employee well-being and sick leave, occupational accident, and disability pension. METHODS: A random population of 967 civil servants participated in a survey on psychosocial factors and health at work in 2000 in Finland. The median follow-up time was 7.3 years. RESULTS: The risks of sick leave and disability pension were decreased by job satisfaction (RR = 0.78, 95% CI = 0.58 to 1.05; RR = 0.47, CI = 0.20 to 1.06; respectively), good work ability (RR = 0.35, CI = 0.22 to 0.56; RR = 0.11, CI = 0.04 to 0.33), good health (RR = 0.42, CI = 0.27 to 0.64; RR = 0.32, CI = 0.11 to 0.98), and strong sense of coherence (RR = 0.53, CI = 0.36 to 0.79; RR = 0.17, CI = 0.07 to 0.37). Employee well-being was also associated with occupational accident but somewhat less consistently. CONCLUSIONS: Employee well-being is associated with sick leave, occupational accident, and disability pension. It is important to find means to support employee well-being both in general and at work.

Economic evaluation of a geriatric rehabilitation programme: a randomized controlled trial.

OBJECTIVE: Cost-effectiveness of a geriatric rehabilitation programme. DESIGN: Economic evaluation alongside a randomized controlled trial. METHODS: A total of 741 subjects with progressively decreasing functional ability and unspecific morbidity were randomly assigned to either an inpatient rehabilitation programme (intervention group) or standard care (control group). The difference between the mean cost per person for 12 months' care in the rehabilitation and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated. Clinical outcomes were functional ability (Functional Independence Measure (FIM(TM))) and health-related quality of life (15D score). RESULTS: The FIM(TM) score decreased by 3.41 (standard deviation 6.7) points in intervention group and 4.35 (standard deviation 8.0) in control group (p = 0.0987). The decrease in the 15D was equal in both groups. The mean incremental cost of adding rehabilitation to standard care was 3111 euros per person. The incremental cost-effectiveness ratio for FIMTM did not show any clinically significant change, and the rehabilitation was more costly than standard care. A cost-effectiveness acceptability curve suggests that if decision-makers were willing to pay 4000 euros for a 1-point improvement in FIMTM, the rehabilitation would be cost-effective with 70% certainty. CONCLUSION: The rehabilitation programme was not cost-effective compared with standard care, and further development of outpatient protocols may be advisable.

Social support as a predictor of disability pension: the Finnish Health 2000 study.

OBJECTIVE: Social support at work and in private life was examined as a predictor of disability pension in the population-based Finnish Health 2000 study. METHODS: Social support was measured in a nationally representative sample comprising of 3414 employees aged 30 to 64 years. Disability pensions extracted from the registers of the Finnish Centre for Pensions were followed up across 6 years. RESULTS: Low social support from supervisors was associated with disability pension with an odds ratio of 1.70 (95% confidence interval, 1.21 to 2.38) when adjusted with sociodemographic and health behavior variables. After adjustment for baseline perceived health, the associations between supervisor support and disability pension strongly attenuated. CONCLUSIONS: Low social support from supervisors predicts forthcoming work disability but the relationship is affected by self-reported nonoptimal health at baseline.

The association of social support at work and in private life with sleeping problems in the Finnish health 2000 study.

OBJECTIVE: To investigate the associations of social support at work and in private life with sleeping problems and use of sleep medication. METHODS: In the nationwide Health 2000 Study, with a cohort of 3430 employees, social support at work and in private life, and sleep-related issues were assessed with self-assessment scales. Purchases of sleep medication over a 3-year period were collected from the nationwide pharmaceutical register of the Social Insurance Institution. RESULTS: Low social support from supervisor was associated with tiredness (odds ratio [OR] 1.68, 95% confidence interval [CI] = 1.26 to 2.23) and sleeping difficulties within the previous month (OR 1.74, 95% CI = 1.41 to 1.92). Low support from coworkers was associated with tiredness (OR 1.55, 95% CI = 1.41 to 1.92), sleeping difficulties within the previous month (OR 1.77, 95% CI = 1.32 to 2.36), and only among women, with short sleep duration (OR 2.06, 95% CI = 1.22 to 3.47). Low private life support was associated with short sleep duration (OR 1.49, 95% CI = 1.13 to 1.98) and among women, with sleeping difficulties (OR 1.46, 95% CI = 1.08 to 1.33). CONCLUSIONS: Low social support, especially at work, is associated with sleeping-related problems.

A comparison of two multidisciplinary inpatient rehabilitation programmes for fibromyalgia: a register linkage study on work disability.

BACKGROUND: Patients with fibromyalgia have a high risk of temporary and permanent work disability. Little is known about the effects of fibromyalgia rehabilitation on work disability. OBJECTIVE: To determine whether a specific fibromyalgia rehabilitation programme is superior to a non-specific musculoskeletal rehabilitation of patients with fibromyalgia in terms of work disability. METHODS: A prospective observational study of 215 local government employees with a 6-year post-intervention follow-up to monitor the occurrence of long sick-leave and disability pensions among the participants of two different fibromyalgia rehabilitation programmes. RESULTS: Specific fibromyalgia rehabilitation was not superior to a non-specific musculoskeletal rehabilitation, with the corresponding hazard ratios (95% confidence intervals) after adjustments being 1.02 (0.75-1.40) for long sick-leave, 1.18 (0.75-1.87) for very long sick-leave, and 1.07 (0.63-1.83) for disability pension. CONCLUSION: The results suggest that in reducing work disability among patients with fibromyalgia a specific multidisciplinary fibromyalgia rehabilitation programme practised in Finland provides no benefit compared with non-specific multidisciplinary musculoskeletal rehabilitation. Further research is needed to develop an optimal programme (or several different programmes) to control the burden of work disability related to fibromyalgia.

The association of social support at work and in private life with mental health and antidepressant use: the Health 2000 Study.

BACKGROUND: Social support is assumed to protect mental health, but it is not known whether low social support at work increases the risk of common mental disorders or antidepressant medication. This study, carried out in Finland 2000-2003, examined the associations of low social support at work and in private life with DSM-IV depressive and anxiety disorders and subsequent antidepressant medication. METHODS: Social support was measured with self-assessment scales in a cohort of 3429 employees from a population-based health survey. A 12-month prevalence of depressive or anxiety disorders was examined with the Composite International Diagnostic Interview (CIDI), which encompasses operationalized criteria for DSM-IV diagnoses and allows the estimation of DSM-IV diagnoses for major mental disorders. Purchases of antidepressants in a 3-year follow-up were collected from the nationwide pharmaceutical register of the Social Insurance Institution. RESULTS: Low social support at work and in private life was associated with a 12-month prevalence of depressive or anxiety disorders (adjusted odds ratio 2.02, 95% CI 1.48-2.82 for supervisory support, 1.65, 95% CI 1.05-2.59 for colleague support, and 1.62, 95% CI 1.12-2.36 for private life support). Work-related social support was also associated with subsequent antidepressant use. LIMITATIONS: This study used a cross-sectional analysis of DSM-IV mental disorders. The use of purchases of antidepressant as an indicator of depressive and anxiety disorders can result in an underestimation of the actual mental disorders. CONCLUSIONS: Low social support, both at work and in private life, is associated with DSM-IV mental disorders, and low social support at work is also a risk factor for mental disorders treated with antidepressant medication.

Network-based rehabilitation increases formal support of frail elderly home-dwelling persons in Finland: randomised controlled trial.

The AGE study is a national randomised, long-term, multicentre research project aimed at comparing a new network-based rehabilitation programme with the use of standard health and social services. The use of home help services is associated with increasing age, living alone and having difficulties with activities of daily living. During a rehabilitation intervention the elderly participants' need for care can be assessed. The focus of this paper is to investigate the possible effects of the network-based rehabilitation programme on the use of informal and formal support among home-dwelling elderly at a high risk of long-term institutionalisation. The randomised controlled trial with a 12-month follow-up was implemented in 7 rehabilitation centres and 41 municipalities in Finland. The participants were recruited between January and October 2002. A total of 708 home-dwelling persons aged 65 years or older with progressively decreasing functional capacity and at the risk of being institutionalised within 2 years participated. Persons with acute or progressive diseases or poor cognitive capacity (Mini Mental State Examination<18 points), and those who had participated in any inpatient rehabilitation during the preceding 5 years, were excluded. Participants were randomly allocated to the intervention group (n=343) or to the control group (n=365). The intervention consisted of a network-based rehabilitation programme specifically designed for frail elderly people. Main outcome measures included the help received from relatives and municipal or private services. The use of municipal services increased more in the intervention group (P<0.05) than in the control group. Support from relatives decreased in the control group. The rehabilitees' ability to manage with daily activities decreased and they received additional help; hence, in this respect the rehabilitation model seems successful. A longer follow-up within the still ongoing AGE study is needed to verify whether the programme actually can delay long-term care.

Network-based geriatric rehabilitation for frail elderly people: feasibility and effects on subjective health and pain at one year.

OBJECTIVE: To study the feasibility and 1-year effects on subjective health and symptoms of a network-based geriatric rehabilitation intervention for frail elderly people. DESIGN: A randomized, controlled trial. SUBJECTS: A total of 741 frail elderly people who lived at home, aged > 65 years, without severe cognitive impairment (Mini Mental State Examination < 18), and eligible to receive Pensioners' Care Allowance (a benefit that is independent of personal income or insurance). The setting included 41 municipalities and 7 rehabilitation centres in Finland. METHODS: Over a period of 8 months the intervention group received network-based rehabilitation for 3 in-patient periods (totalling 21 days) at rehabilitation centres and a home visit by a professional. Both groups received standard social and health services locally. Functional Independence Measure, subjective health, common symptoms and pain were assessed at baseline and 1-year follow-up. RESULTS: After baseline measurements, 33 of those allocated to rehabilitation withdrew from the study. Of the 343 intervention subjects, 276 attended all 3 in-patient periods. At one year, there were no differences in symptoms between the groups. Subjective health was improved in the intervention group and impaired in the control group (p < 0.01). CONCLUSION: The network-based geriatric rehabilitation programme was feasible for use among the frail elderly people and improved their subjective health.

A network-based rehabilitation model for frail elderly people: development and assessment of a new model.

INTRODUCTION AND PURPOSE: Living independently at home promotes the well-being of people aged 65 and over. In Finland, the municipalities are responsible for providing social and health services, including rehabilitation of the elderly. Rehabilitation is in practice carried out by independent rehabilitation centres. The Social Insurance Institution of Finland is a national agency responsible for financing and developing rehabilitation. Combining the efforts of these three agencies, a new network-based inpatient rehabilitation model was established to support the community living of frail elderly persons at high risk of institutionalization. This article describes the new model and evaluates the cooperation within the rehabilitation network, as well as the contents of the rehabilitation. MATERIAL AND METHODS: The new model was evaluated in two phases using diverse methods. First, the networks were assessed as they were being established in 2000, and secondly, when they were operational in 2002. The first phase involved 53 networks operating in 46 municipalities and 12 rehabilitation centres, and the second 44 networks in 41 municipalities and seven rehabilitation centres. The data were collected by questionnaires, interviews and reports. RESULTS: The rehabilitation networks were functional, although constant development and search for better working practices was time consuming. Two different approaches in the networks were found: the 'networks of creators' were able to carry out the new tasks highly successfully, while the 'networks of followers' only managed to do the minimum as instructed. Motivated network members and adequate resources appeared to be essential for a successful rehabilitation process. CONCLUSIONS: It is possible to create a functional rehabilitation network involving different agencies. Further development work is necessary to make the network-based rehabilitation model more efficient.

Allocation of rehabilitation measures provided by the Social Insurance Institution in Finland: a register linkage study.

OBJECTIVE: To study the allocation of rehabilitation measures provided by the Finnish Social Insurance Institution in relation to the characteristics and health status of rehabilitants. DESIGN: A register linkage study. SUBJECTS: A total of 67,106 full-time local government employees with a minimum of 10-month job contracts in 10 Finnish towns during the period 1994-2002. METHODS: Data on the rehabilitation granted between 1994 and 2002, special medication reimbursements for chronic diseases, and disability retirement, were derived from the registers of the Social Insurance Institution as an indicator of chronic morbidity and linked to the employers' records on demographic characteristics and rates of sickness absence. RESULTS: In comparison with non-rehabilitants, the rate of sickness absence (> 21 days) was 2.2-2.9-fold (95% confidence interval (CI) 2.0-3.0) higher, the odds ratios of special medication reimbursement 1.5-6.1-fold (95% CI 1.3-6.9) higher and disability retirement 3.1-7.5-fold (95% CI 2.7-9.3) higher among rehabilitants. Older women and employees in manual or lower-grade non-manual jobs predominated in the rehabilitation groups. The proportion of temporary employees receiving rehabilitation was low. CONCLUSION: Permanently employed older women with an excess burden of health problems predominate in the receipt of rehabilitation provided by the Social Insurance Institution.

A network-based geriatric rehabilitation programme: study design and baseline characteristics of the patients.

The objective of this paper is to present the design and participants of an ongoing randomized controlled trial on a network-based geriatric rehabilitation programme, targeted at frail elderly persons with progressively declining health and a high risk of institutionalization. Forty-one municipalities, seven rehabilitation centres and a total of 741 frail elderly (65+years) community-living persons participated in the study. Assessments included measurements of physical capacity (balance, handgrip strength, walking speed), Functional Independence Measure, Geriatric Depression Scale, 15 Dimension quality of life questionnaire and Mini Mental State Examination. Questionnaires covered physical, social and psychological factors. The participants were old (mean age 78 years, range 65-96) and mainly female (86%). They were physically frail and most of them (66%) had experienced deterioration of health within 1 year. The majority lived alone (72%) and received regular help from other people (99%). The mean Mini Mental State Examination and Geriatric Depression Scale scores were 25.2 and 4.1 points, respectively. Depressive mood (Geriatric Depression Scale>6 points) was found in 17% and declined cognitive function (Mini Mental State Examination<24 points) in 28% of the participants. Differences between the randomized intervention and control groups were insignificant. Since the number of participants is sufficient statistically, the prospects for evaluating the effectiveness of the programme, and identifying potential benefactors, are good.