Early multidisciplinary assessment was associated with longer periods of sick leave: a randomized controlled trial in a primary health care centre.

OBJECTIVE: To study the effects on sick leave from an early multidisciplinary assessment at a primary health care centre. DESIGN: Randomized controlled trial. SETTING: Patients who saw GPs at a primary health care centre in mid-Sweden and asked for a sickness certificate for psychiatric or musculoskeletal diagnoses were invited to participate. Patients included were sick-listed for less than four weeks; 33 patients were randomized either to an assessment within a week by a physiotherapist, a psychotherapist, and an occupational therapist or to "standard care". The therapists used methods and tools they normally use in their clinical work. MAIN OUTCOME MEASURE: Proportion of patients still sick-listed three months after randomization, total and net days on sick leave, and proportion who were on part-time sick leave. Results. At follow-up after three months, in contrast to the pre-trial hypothesis, there was a trend toward a higher proportion of patients still sick-listed in the intervention group (7/18) as compared with the control group (3/15). The intervention group also had significantly longer sick-listing periods (mean 58 days) than the control group (mean 36 days) (p = 0.038). The proportion of patients who were part time sick-listed was significantly higher in the intervention group (10/18) than in the control group (2/15) (p = 0.027). CONCLUSIONS: In this study an early multidisciplinary assessment was associated with longer periods on sick leave and more individuals on part-time sick leave.

When physicians get stuck in sick-listing consultations: a qualitative study of categories of sick-listing dilemmas.

OBJECTIVE: Many physicians find sick-listing tasks problematic. The aim of this study was to identify categories of dilemmas experienced by physicians in their sick-listing practice. DESIGN AND SUBJECTS: Data was collected at courses that were aimed at improving physicians' sick-listing skills, arranged in different parts of Sweden. Before the course the participants, general practitioners (GP) sent in a written report of a sick-listing case they found problematic. The material consisted of group discussions of some 100 case reports from GPs. The process of categorisation of the dilemmas was a one-step, straightforward qualitative analysis. RESULTS: Eight different categories of sick-listing dilemmas experienced by the physicians were identified. Examples of them are "Not the doctors' pigeon" (when the patients' problem was perceived as not being medical in nature), "Diagnosis as disguise" (when there is a discrepancy between how the patient describes the problems and what the physician apprehends), and "Harmed by sick listing-reversible" (when the physician perceives that the main problem is the iatrogenic adverse effects of sick listing per se). IMPLICATIONS: The contribution of the study is to provide understanding of and labels to the specific difficulties experienced by physicians in their sick-listing practice face to face with patients.

Asymptomatic bacteriuria in the elderly: high prevalence and high turnover of strains.

Asymptomatic bacteriuria (ASB) was followed in repeated prevalence surveys in a cohort of non-institutionalized residents (n=330), aged>or=80 y. Urine samples were collected at baseline, and at 6, and at 18 months. Phenotyping (PhenePlate) was performed on isolates of Escherichia coli to evaluate strain relatedness. ASB occurred in 19.0, 19.4, and 19.9% in women, and in 9.4, 9.6 and 7.9% in men, at baseline and at the 6- and 18-months follow-up, respectively, and ASB was found at least once in 37% of women and in 20% of men. Of those with ASB at baseline, 60% also had ASB in the 2 subsequent surveys. Among those with persisting E. coli bacteriuria, 76% and 40%, respectively, carried the same strain at the 6- and 18-months follow-ups. In women, we found that the risk of developing a symptomatic urinary tract infection within 24 months was higher among those with ASB at baseline than in those without bacteriuria (p=0.019). ASB is common and often persistent, but we found a high turnover of strains, indicating a high rate of recolonization.

Bacteriuria is associated with urge urinary incontinence in older women.

OBJECTIVE: To investigate the association between bacteriuria and frequency and type of urinary incontinence in elderly people living in the community. Bacteriuria and urinary incontinence are common conditions and often coexisting in this population; the authors have previously reported the prevalence of bacteriuria to be 22.4% in women and 9.4% in men. DESIGN: Cross-sectional study. SETTING: The catchment area of a primary healthcare centre in a Swedish middle-sized town. SUBJECTS: Residents, except for those in nursing homes, aged 80 and over. Participation rate: 80.3% (431/537). MAIN OUTCOME MEASURES: Urinary cultures and questionnaire data on urinary incontinence. RESULTS: In women the OR for having bacteriuria increased with increasing frequency of urinary incontinence; the OR was 2.83 (95% CI 1.35-5.94) for women who were incontinent daily as compared with continent women. Reporting urge urinary incontinence increased the risk of having bacteriuria: 3.36 (95% CI 1.49-7.58) in comparison with continent women while there was no significant association between stress urinary incontinence and bacteriuria. The prevalence of bacteriuria among men was too low to make any meaningful calculations about the association between bacteriuria and frequency and type of incontinence. CONCLUSION: Bacteriuria is associated with more frequent leakage and predominantly with urge urinary incontinence. The causes of this association and their clinical implications remain unclear. There might be some individuals who would benefit from antibiotic treatment, but further studies are warranted.

Asymptomatic bacteriuria in a population of elderly residents living in a community setting: prevalence, characteristics and associated factors.

BACKGROUND: Asymptomatic bacteriuria (ASB) is common among the elderly in institutional care, but less is known about its prevalence among the elderly living in community settings. Knowledge of the prevalence of ASB in this population could contribute to a reduction in unnecessary use of antibiotics. OBJECTIVE: To study the prevalence of ASB and associated health and social factors in a population of elderly people, aged 80 and over, in a community setting. DESIGN: A cross-sectional study. SETTING: The catchment area of a primary health care centre in a Swedish middle-sized town. METHOD: All residents, aged 80 and over, except for those in institutional living, were invited. A structured interview was carried out and urinary culture obtained. RESULTS: ASB was found in 14.8% of the participants, in 19.0% of the women and 5.8% of the men. In women independent associations with ASB were found for urinary incontinence (OR: 2.99, CI: 1.60-5.60), reduced mobility (OR: 2.68, CI: 1.42-5.03) and oestrogen treatment (OR: 2.20, CI: 1.09-4.45). CONCLUSION: Bacteriuria is common among the elderly living in non-institutional community settings, especially among women, although not as common as among the elderly in institutional settings. A woman over 80, with urinary incontinence, and needing support to walk has a risk of nearly 50% of presenting with ASB, a condition about which there is consensus not to treat with antibiotics. This should be borne in mind when examining patients with diffuse symptomatology and an accidental finding of bacteriuria.

["Not the doctor's pigeon"--a common dilemma in sick-listing consultations]. / "Inte doktorns bord"--ett vanligt dilemma i sjukskrivningskonsultationer.

The role played by doctors in the high sick-listing figures is a subject of vigorous discussion. The point of departure for the course "The generalpractitioner and the medical certificate" is that the doctor can combine concern for the patient with objective assessment. With the course participants' own sick-listing cases as material, it has been possible to categorize the difficulties. One such category is "Not the doctor's pigeon", when the doctor sees that the patients' problems concerning sick-listing would be better handled by, for example, the employer, the employment office, the social insurance office, or the patient himself. The categories found can be regarded as a practical support for the doctor in considering and discovering alternative actions.