Recurrent acute otitis media: a survey of current management in England.

OBJECTIVE: Recurrent acute otitis media is common in children. The preferred treatment measures for recurrent acute otitis media have a mixed evidence base. This study sought to assess baseline practice across ENT departments in England. METHODS: A national telephone survey of healthcare staff was conducted. Every ENT centre in England was contacted. A telephone script was used to ask about antibiotic and grommet use and duration in recurrent acute otitis media cases. RESULTS: Ninety-six centres (74 per cent) provided complete information. Recurrent acute otitis media treatment across England by ENT departments varied. The antibiotic first- and second-line prophylaxis offered varies, with trimethoprim used in 33 centres and 29 centres not offering any antibiotics. The timing or choice about when to use grommets also varies, but 87 centres (91 per cent) offer grommet surgery at one stage. CONCLUSION: The treatments received by children in England for recurrent acute otitis media vary by centre; collaborative research in this area is advised.

Support service utilization and out-of-pocket payments for health services in a population-based sample of adults with neurological conditions.

BACKGROUND: Social support can help to deal with the consequences of neurological conditions and promote functional independence and quality of life. Our aim was to evaluate the impact of neurological conditions on the use of support and health-care services in a population-based sample of community-dwelling adults with neurological conditions. METHODS: Data were from the Survey of Living with Neurological Conditions in Canada, which was derived from a representative sample of household residents. Formal and informal support received and out-of-pocket payments were assessed by personal interviews. Logistic regression was used to explore the association between support service utilization and six common neurological conditions (Stroke, Parkinson's disease, Alzheimer's disease/dementias, traumatic brain injury, spinal cord injury and multiple sclerosis) with stroke as the reference category. RESULTS: The sample contained 2,410 respondents and equate to an estimated 459,770 when sample weights were used. A larger proportion of people within each of the neurological conditions received informal support than formal support (at least twice as much). Samples with the non-stroke conditions were more likely to receive formal assistance for personal (odds ratios 2.7 to 5.6; P < 0.05) and medical (odds ratios 2.4 to 4.4; P < 0.05) care compared to the stroke group. Also, the non-stroke conditions were more likely to receive informal assistance (odds ratios 2.7 to 17.9; P < 0.05) and less likely to make out-of-pocket payments for rehabilitation therapy (odds ratios 0.2 to 0.3; P < 0.05) than the stroke group. The Alzheimer's disease/dementia group had the highest proportion who received formal and informal support services. CONCLUSIONS: Our findings suggest that Canadians with neurological conditions receive more informal assistance than formal assistance. Furthermore, it appears that stroke survivors receive less support services, while those with Alzheimer's disease/dementia receive the most compared to other adult neurological conditions. Such data can help inform the development of support services in the community.

Knowledge, attitudes, and practices of private sector immunization service providers in Gujarat, India.

BACKGROUND: India is responsible for 30% of the annual global cohort of unvaccinated children worldwide. Private practitioners provide an estimated 21% of vaccinations in urban centers of India, and are important partners in achieving high vaccination coverage. METHODS: We used an in-person questionnaire and on-site observation to assess knowledge, attitudes, and practices of private immunization service providers regarding delivery of immunization services in the urban settings of Surat and Baroda, in Gujarat, India. We constructed a comprehensive sampling frame of all private physician providers of immunization services in Surat and Baroda cities, by consulting vaccine distributors, local branches of physician associations, and published lists of private medical practitioners. All providers were contacted and asked to participate in the study if they provided immunization services. Data were collected using an in-person structured questionnaire and directly observing practices; one provider in each practice setting was interviewed. RESULTS: The response rate was 82% (121/147) in Surat, and 91% (137/151) in Baroda. Of 258 participants 195 (76%) were pediatricians, and 63 (24%) were general practitioners. Practices that were potential missed opportunities for vaccination (MOV) included not strictly following vaccination schedules if there were concerns about ability to pay (45% of practitioners), and not administering more than two injections in the same visit (60%). Only 22% of respondents used a vaccination register to record vaccine doses, and 31% reported vaccine doses administered to the government. Of 237 randomly selected vaccine vials, 18% had expired vaccine vial monitors. CONCLUSIONS: Quality of immunization services in Gujarat can be strengthened by providing training and support to private immunization service providers to reduce MOVs and improve quality and safety; other more context specific strategies that should be evaluated may involve giving feedback to providers on quality of services delivered and working through professional societies to adopt standards of practice.

US Spending on Personal Health Care and Public Health, 1996-2013.

Importance: US health care spending has continued to increase, and now accounts for more than 17% of the US economy. Despite the size and growth of this spending, little is known about how spending on each condition varies by age and across time. Objective: To systematically and comprehensively estimate US spending on personal health care and public health, according to condition, age and sex group, and type of care. Design and Setting: Government budgets, insurance claims, facility surveys, household surveys, and official US records from 1996 through 2013 were collected and combined. In total, 183 sources of data were used to estimate spending for 155 conditions (including cancer, which was disaggregated into 29 conditions). For each record, spending was extracted, along with the age and sex of the patient, and the type of care. Spending was adjusted to reflect the health condition treated, rather than the primary diagnosis. Exposures: Encounter with US health care system. Main Outcomes and Measures: National spending estimates stratified by condition, age and sex group, and type of care. Results: From 1996 through 2013, $30.1 trillion of personal health care spending was disaggregated by 155 conditions, age and sex group, and type of care. Among these 155 conditions, diabetes had the highest health care spending in 2013, with an estimated $101.4 billion (uncertainty interval [UI], $96.7 billion-$106.5 billion) in spending, including 57.6% (UI, 53.8%-62.1%) spent on pharmaceuticals and 23.5% (UI, 21.7%-25.7%) spent on ambulatory care. Ischemic heart disease accounted for the second-highest amount of health care spending in 2013, with estimated spending of $88.1 billion (UI, $82.7 billion-$92.9 billion), and low back and neck pain accounted for the third-highest amount, with estimated health care spending of $87.6 billion (UI, $67.5 billion-$94.1 billion). The conditions with the highest spending levels varied by age, sex, type of care, and year. Personal health care spending increased for 143 of the 155 conditions from 1996 through 2013. Spending on low back and neck pain and on diabetes increased the most over the 18 years, by an estimated $57.2 billion (UI, $47.4 billion-$64.4 billion) and $64.4 billion (UI, $57.8 billion-$70.7 billion), respectively. From 1996 through 2013, spending on emergency care and retail pharmaceuticals increased at the fastest rates (6.4% [UI, 6.4%-6.4%] and 5.6% [UI, 5.6%-5.6%] annual growth rate, respectively), which were higher than annual rates for spending on inpatient care (2.8% [UI, 2.8%-2.8%] and nursing facility care (2.5% [UI, 2.5%-2.5%]). Conclusions and Relevance: Modeled estimates of US spending on personal health care and public health showed substantial increases from 1996 through 2013; with spending on diabetes, ischemic heart disease, and low back and neck pain accounting for the highest amounts of spending by disease category. The rate of change in annual spending varied considerably among different conditions and types of care. This information may have implications for efforts to control US health care spending.

Language Services In Hospitals Vary By Ownership And Location.

Twenty-four million people in the United States have limited English proficiency. They experience barriers to health care because of their inability to communicate effectively with providers. Hospitals are required to provide language services that reflect the needs of people in their communities, but these services are not available systematically.

A Personal Health Network for Chemotherapy Care Coordination: Evaluation of Usability Among Patients.

Cancer is a top concern globally. Cancer care suffers from lack of coordination, silos of information, and high cost. Interest is emerging in person-centered technology to assist with coordination to address these challenges. This study evaluates the usability of the "personal health network" (PHN), a novel solution leveraging social networking and mobile technologies, among individuals undergoing chemotherapy and receiving care coordination. Early results from interviews of 12 participants in a randomized pragmatic trial suggest that they feel more connected to the healthcare team using the PHN, find value in access to the patient education library, and are better equipped to organize the many activities that occur during chemotherapy. Improvements are needed in navigation, connectivity, and integration with electronic health records. Findings contribute to improvements in the PHN and informs a roadmap for potentially greater impact in technology-enabled cancer care coordination.

The acceptance of personal health devices among patients with chronic conditions.

BACKGROUND: Personal health devices (PHDs) are rapidly developing and getting smarter. But little is known about chronic patients' acceptance of such PHDs. OBJECTIVE: The objective of this study is to explore how chronic patients accept PHDs and what are the main factors that predict use intention of PHDs. The results will provide suggestions for the design of PHDs and e-health services. METHOD: A questionnaire survey was conducted to identify the main factors that affect chronic patients' acceptance of PHDs. Three hundred and forty-six valid responses from chronic patients were collected and the data were analyzed using exploratory factor analysis and regression analysis method. The questionnaire also included questions about respondents' experience of PHDs and preference of PHD functions. These questions help to understand lived experience of PHD users and to explain the factors that influence their use intention. RESULT: Five influencing factors that predict use intention of PHDs were identified: attitude toward technology, perceived usefulness, ease of learning and availability, social support, and perceived pressure. An acceptance model of PHDs was proposed based on these factors, and suggestions for PHD designers and e-health service designers were discussed. The exploration of PHD experience indicated that ease of learning and social norm significantly influenced PHD use intention, and many respondents expressed negative opinions on the accuracy, durability and maintenance service of PHDs. Besides, people generally expressed positive attitude toward future functions of a PHD.

Payment rates for personal care assistants and the use of long-term services and supports among those dually eligible for Medicare and Medicaid.

OBJECTIVE: To examine the association between payment rates for personal care assistants and use of long-term services and supports (LTSS) following hospital discharge among dual eligible Medicare and Medicaid beneficiaries. DATA SOURCES: State hospital discharge, Medicaid and Medicare claims, and assessment data on California Medicaid LTSS users from 2006 to 2008. STUDY DESIGN: Cross-sectional study. We used multinomial logistic regression to analyze county personal care assistant payment rates and postdischarge LTSS use, and estimate marginal probabilities of each outcome across the range of rates paid in California. DATA EXTRACTION METHODS: We identified dual eligible Medicare and Medicaid adult beneficiaries discharged from an acute care hospital with no hospitalizations or LTSS use in the preceding 12 months. PRINCIPAL FINDINGS: Personal care assistant payment rates were modestly associated with home and community-based services (HCBS) use versus nursing facility entry following hospital discharge (RRR 1.2, 95 percent CI: 1.0-1.4). For a rate of $6.75 per hour, the probability of HCBS use was 5.6 percent (95 percent CI: 4.2-7.1); at $11.75 per hour, 18.0 percent (95 percent CI: 12.5-23.4). Payment rate was not associated with the probability of nursing facility entry. CONCLUSIONS: Higher payment rates for personal care assistants may increase utilization of HCBS, but with limited substitution for nursing facility care.

Systematic evaluation of personal genome services for Japanese individuals.

Disease risk prediction (DRP) is one of the most important challenges in personal genome research. Although many direct-to-consumer genetic test (DTC) companies have begun to offer personal genome services for DRP, there is still no consensus on what constitutes a gold-standard service. Here, we systematically evaluated the distributions of DRPs from three DTC companies, that is, 23andMe, Navigenics and deCODEme, for 22 diseases using three Japanese samples. We systematically quantified and analyzed the differences between each DTC company's DRPs. Our independency test showed that the overall prediction results were correlated with each other, but not perfectly matched; less than onethird mismatching of the opposite direction occurred in eight diseases. Moreover, we found that the differences could mainly be attributed to four factors: (1) single nucleotide polymorphism (SNP) selection, (2) average risk estimation, (3) the disease risk calculation algorithm and (4) ethnicity adjustment. In particular, only 7.1% of SNPs over 22 diseases were reviewed by all three companies. Therefore, development of a universal core SNPs list for non-Caucasian samples will be important for achieving better prediction capacity for Japanese samples. This systematic methodology provides useful insights for improving the capacity of DRPs in future personal genome services.

Personal service assistance: musculoskeletal disorders and injuries in consumer-directed home care.

BACKGROUND: Like other types of care for disabled or elderly adults, consumer-directed personal assistance services may present multi-factorial risks for work-related musculoskeletal disorders (WRMSDs). METHODS: Using survey data, we compared providers experiencing WRMSDs in the previous year to those who did not, seeking to identify functional, temporal, physical, and relationship risk factors for transient and chronic conditions. RESULTS: Longer work experience with the recipient and more frequent bending increased the risk of being in the most chronic group (≥12 painful episodes), whereas predictable work hours with rest breaks and greater social support from the recipient appeared protective. For transient conditions (one to two episodes), longer work experience with the recipient and predictable hours with rest breaks appeared protective. CONCLUSIONS: We offer recommendations to improve hazard assessment as well as training and information distribution related to home care programs. With the population aging, home care jobs require increasing oversight to prevent WRMSDs.

Healthcare utilization and barriers for youth post-detention.

AIM: Adolescents in the juvenile justice system are particularly susceptible to high rates of co-occurring health-risk behaviors, while at the same time lacking access to the healthcare system. METHODS: A verbal questionnaire was administered from December 2009 to June 2010 to youth between the ages of 13-17 years old, who had previously been detained in an urban juvenile detention facility in California. RESULTS: A total of 50 participants were enrolled in the study (40% female, 60% male, 16 years mean age, 80% Black, 18% Latino, 2% White). The mean time post-detention was 15 months, and the mean time in detention was 4 months. Our study provides evidence that adolescents exiting juvenile detention in the United States are interested in gaining access to healthcare providers but perceive lack of insurance and transportation as barriers to care. These barriers need to be addressed in order to facilitate access to healthcare services for this underserved and at-risk population of youth.

A multistate examination of partnership activity among local public health systems using the National Public Health Performance Standards.

This study examines whether partnership-related measures in the second version of the National Public Health Performance Standards (NPHPS) are useful in evaluating level of activity as well as identifying latent constructs that exist among local public health systems (LPHSs). In a sample of 110 LPHSs, descriptive analysis was conducted to determine frequency and percentage of 18 partnership-related NPHPS measures. Principal components factor analysis was conducted to identify unobserved characteristics that promote effective partnerships among LPHSs. Results revealed that 13 of the 18 measures were most frequently reported at the minimal-moderate level (conducted 1%-49% of the time). Coordination of personal health and social services to optimize access (74.6%) was the most frequently reported measure at minimal-moderate levels. Optimal levels (conducted >75% of the time) were reported most frequently in 2 activities: participation in emergency preparedness coalitions and local health departments ensuring service provision by working with state health departments (67% and 61% of respondents, respectively) and the least optimally reported activity was review partnership effectiveness (4% of respondents). Factor analysis revealed categories of partnership-related measures in 4 domains: resources and activities contributing to relationship building, evaluating community leadership activities, research, and state and local linkages to support public health activities. System-oriented public health assessments may have questions that serve as proxy measures to examine levels of interorganizational partnerships. Several measures from the NPHPS were useful in establishing a national baseline of minimal and optimal activity levels as well as identifying factors to enhance the delivery of the 10 essential public health services among organizations and individuals in public health systems.

A comparison between physicians and demographically similar peers in accessing personal health care.

PURPOSE: Residents are a unique subpopulation of physicians, training in a complex work and educational environment that may create barriers to accessing preventive and illness-related health care. This study was designed to investigate residents' utilization of personal health care services and compare with those of demographically similar peers. METHOD: All 675 residents in a large, urban, tertiary care U.S. academic medical center were invited to participate in a confidential, Web-based, cross-sectional survey in January 2008. Survey responses to questions addressing personal health care were compared with those of a demographically similar group using the 2008 survey from the Behavioral Risk Factor Surveillance System (BRFSS). The final weights in BRFSS were used for a post hoc stratified adjustment in analysis. Logistic regression was employed to compare subgroups. RESULTS: Sixty-six percent of residents completed the survey. A significantly lower percentage of residents reported having a primary care provider (44%) or dentist (65%) or having routine health and dental care visits (39% and 53%, respectively) within the past year than those in the demographically similar group of 2008 BRFSS. In that group, 83% reported having a primary care provider, and 63% and 79% reported having routine primary and dental health care visits, respectively. CONCLUSIONS: The residents were significantly less likely than demographically similar peers to have a primary care provider or dentist or to participate in routine health maintenance. Further research into barriers preventing residents from accessing health care, and opportunities to address them, is needed.

Measuring the impact of Hurricane Katrina on access to a personal healthcare provider: the use of the National Survey of Children's Health for an external comparison group.

This paper examined the effect of Hurricane Katrina on children's access to personal healthcare providers and evaluated the use of propensity score methods to compare a nationally representative sample of children, as a proxy for an unexposed group, with a smaller exposed sample. 2007 data from the Gulf Coast Child and Family Health (G-CAFH) Study, a longitudinal cohort of households displaced or greatly impacted by Hurricane Katrina, were matched with 2007 National Survey of Children's Health (NSCH) data using propensity score techniques. Propensity scores were created using poverty level, household educational attainment, and race/ethnicity, with and without the addition of child age and gender. The outcome was defined as having a personal healthcare provider. Additional confounders (household structure, neighborhood safety, health and insurance status) were also examined. All covariates except gender differed significantly between the exposed (G-CAFH) and unexposed (NSCH) samples. Fewer G-CAFH children had a personal healthcare provider (65 %) compared to those from NSCH (90 %). Adjusting for all covariates, the propensity score analysis showed exposed children were 20 % less likely to have a personal healthcare provider compared to unexposed children in the US (OR = 0.80, 95 % CI 0.76, 0.84), whereas the logistic regression analysis estimated a stronger effect (OR = 0.28, 95 % CI 0.21, 0.39). Two years after Hurricane Katrina, children exposed to the storm had significantly lower odds of having a personal health care provider compared to unexposed children. Propensity score matching techniques may be useful for combining separate data samples when no clear unexposed group exists.

An assessment of the construct validity of the ASCOT measure of social care-related quality of life with older people.

BACKGROUND: The adult social care outcomes toolkit (ASCOT) includes a preference-weighted measure of social care-related quality of life for use in economic evaluations. ASCOT has eight attributes: personal cleanliness and comfort, food and drink, control over daily life, personal safety, accommodation cleanliness and comfort, social participation and involvement, occupation and dignity. This paper aims to demonstrate the construct validity of the ASCOT attributes. METHODS: A survey of older people receiving publicly-funded home care services was conducted by face-to-face interview in several sites across England. Additional data on variables hypothesised to be related and unrelated to each of the attributes were also collected. Relationships between these variables and the attributes were analysed through chi-squared tests and analysis of variance, as appropriate, to test the construct validity of each attribute. RESULTS: 301 people were interviewed and approximately 10% of responses were given by a proxy respondent. Results suggest that each attribute captured the extent to which respondents exercised choice in how their outcomes were met. There was also evidence for the validity of the control over daily life, occupation, personal cleanliness and comfort, personal safety, accommodation cleanliness and comfort, and social participation and involvement attributes. There was less evidence regarding the validity of the food and drink and dignity attributes, but this may be a consequence of problems finding good data against which to validate these attributes, as well as problems with the distribution of the food and drink item. CONCLUSIONS: This study provides some evidence for the construct validity of the ASCOT attributes and therefore support for ASCOT's use in economic evaluation. It also demonstrated the feasibility of its use among older people, although the need for proxy respondents in some situations suggests that developing a version that is suitable for proxies would be a useful future direction for this work. Validation of the instrument on a sample of younger social care users would also be useful.

Severity of children's intellectual disabilities and Medicaid personal care services.

OBJECTIVES: This research investigated the relationship between a child's reported intellectual disability (ID) level and caregivers' reports of the child's health status to predict Medicaid Personal Care Services (PCS) hours authorized for that child. We also investigated how activity limitations in the home varied with the level of ID. DESIGN: The sample included 1,108 community-residing children with a reported level of ID in the Texas Medicaid system and who were assessed for the PCS program. All data were collected with the Personal Care Assessment Form (PCAF), an instrument developed by the authors for evaluating children's PCS needs. Case managers completed the PCAF in the child's home with the child and primary caregivers present. Structural equation modeling (SEM) was used to test a model reflecting the role of ID and other characteristics of the child in determining the number of PCS hours authorized. Additional analyses revealed the degree to which variation among the case managers affected the number of hours authorized. RESULTS: ID level and other individual characteristics had a significant effect on reports of a child's activity limitations (R2 = .67), which in turn affected the hours of PCS authorized (R2 = .27). We found no significant direct relationship between ID level and PCS hours: ID level had an indirect relationship on PCS hours through activity limitations. When the variance in hours authorized was decomposed, individual characteristics accounted for 20% of the variance and case managers accounted for 14%. CONCLUSIONS: Assessments of caregiver and child strengths and limitations in the home are critical in the allocation of Medicaid home-based services, above and beyond the information conveyed by demographic and diagnostic data. Implications for home-based assessments of functional limitations and needs for family caregivers and their children with ID are discussed.

Medicaid Personal Care Services and caregivers' reports of children's health: the dynamics of a relationship.

OBJECTIVE: To investigate the relationship between Medicaid Personal Care Services (PCS) and caregivers' reports of activity (activities of daily living [ADL]) limitations for children with chronic health problems. DATA SOURCES/STUDY SETTING: Primary data collected in 2008 and 2009. A state Medicaid program was the setting. The focus was children receiving Medicaid PCS. DATA COLLECTION: Medicaid case managers assessed children to determine their need for PCS, using information provided by the child or informal caregivers. Two thousand seven hundred assessments were provided to researchers directly from case managers. PRINCIPAL FINDINGS: Medical conditions and impairments explained 58 percent of the variance in the child's activity limitations. Activity limitations and problem behaviors explained 28 percent of the variance in PCS hours authorized. Which case manager completed the assessment also played a substantial role in determining hours of care. CONCLUSIONS: Caregivers' reports of the severity of a child's activity limitations effectively summarize the effects of conditions and impairments on the child's ADL performance and have a significant impact on the level of services provided. Assessors often respond differently to children's characteristics and circumstances as they move from assessment to decisions concerning care provision. Our results imply that the provision of appropriate services may be enhanced when both case managers and caregivers play an active role in decisions concerning care provision.

The effect of COPD health forecasting on hospitalisation and health care utilisation in patients with mild-to-moderate COPD.

Exacerbations are a major cause of morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) as well as having a large impact on health care utilisation (HCU). They are more frequent during periods of cold weather with a corresponding increase in hospital admissions. It has been hypothesised that COPD exacerbations and admissions can be reduced by predicting periods of cold weather coupled with patients' alerts and education. Healthy Outlook(®) service provided by the Meteorological Office, UK, was used in patients with mild-to-moderate COPD who consented to participate from three primary care practices. Outcome measures included data relating to hospital admissions for acute exacerbations as well as HCU for these patients during the intervention period (1 Nov 2008-31 Mar 2009) and compared for the same patients and same period 12 months earlier (1 Nov 2007-31 Mar 2008). A cost analysis comparing treatment cost per patient for the two periods was also conducted. A total of 157 (34% of target COPD population) patients took part in the project, with five weather alerts generated (first alert reached 150 patients; second reached 146; third reached 138 patients; fourth reached 137 patients; and the fifth reached 125 patients) during the intervention period. There was a non-statistically-significant increase in hospital admissions per patient (0.07-0.076; p = 0.83). The number of general practice visits per patient dropped from 4.9 to 3.8 (p = 0.001), with drop in average number of visits to patients by out-of-hours services from 0.52-0.14 (p = 0.013). The average number of home consultations provided by general practice increased from 0.05 to 0.92 (p = 0.001). Cost per patient increased by an average of £142 (95% CI -£128 to £412). This anticipatory care model was not associated with reduction in admissions from COPD exacerbations. Further research is required to fully understand its role in the management of patients with COPD.

Work and health, a blind spot in curative healthcare? A pilot study.

INTRODUCTION: Most workers with musculoskeletal disorders on sick leave often consult with regular health care before entering a specific work rehabilitation program. However, it remains unclear to what extent regular healthcare contributes to the timely return to work (RTW). Moreover, several studies have indicated that it might postpone RTW. There is a need to establish the influence of regular healthcare on RTW as outcome; "Does visiting a regular healthcare provider influence the duration of sickness absence and recurrent sick leave due to musculoskeletal disorders?". METHODS: A cohort of workers on sick leave for 2-6 weeks due to a-specific musculoskeletal disorders was followed for 12 months. The main outcomes for the present analysis were: duration of sickness absence till 100% return to work and recurrent sick leave after initial RTW. Cox regression analyses were conducted with visiting a general health practitioner, physical therapist, or medical specialist during the sick leave period as independent variables. Each regression model was adjusted for variables known to influence health care utilization like age, sex, diagnostic group, pain intensity, functional disability, general health perception, severity of complaints, job control, and physical load at work. RESULTS: Patients visiting a medical specialist reported higher pain intensity and more functional limitations and also had a worse health perception at start of the sick leave period compared with those not visiting a specialist. Visiting a medical specialist delayed return to work significantly (HR = 2.10; 95%CI 1.43-3.07). After approximately 8 weeks on sick leave workers visiting a physical therapist returned to work faster than other workers. A recurrent episode of sick leave during the follow up quick was initiated by higher pain intensity and more functional limitations at the moment of fully return to work. Visiting a primary healthcare provider during the sickness absence period did not influence the occurrence of a new sick leave period. CONCLUSION: Despite the adjustment for severity of the musculoskeletal disorder, visiting a medical specialist was associated with a delayed full return to work. More attention to the factor 'labor' in the regular healthcare is warranted, especially for those patients experiencing substantial functional limitations due to musculoskeletal disorders.