Primary care physicians' concerned voices on sickness certification after a period of reorganization. Focus group interviews in Sweden.

Objective: This study explored the views of primary health care (PHC) physicians on sickness certification after reforms in 2005 prompted by the Swedish government to increase the quality and decrease the inequalities, and costs of sickness certification.Design: Qualitative design with focus group interviews. Data were analysed using qualitative content analysis.Setting: Urban and rural PHC centres in Region Västra Götaland, Sweden.Subjects: GPs, interns, GP trainees and locums working in PHC centres 2015. Six focus group interviews with 28 physicians were performed.Main outcome measures: Experiences and reflections about the sickness certification system.Results: The latent content was formulated in a theme: 'The physicians perceived the sickness certification process as emotive and a challenge to master with differing demands and expectations from authorities, management and patients'. Sickness certification could be easy in clear-cut situations or difficult when other factors besides the pure medical were ruling the decisions. The physicians' coping strategies for the task included both active measures (cooperation with health care staff and social insurance officers) and passive adaptation (giving in or not caring too much) to the circumstances. Proposals for the future were to transfer lengthy sickness certifications and rehabilitation to specialized teams and increase cooperation with rehabilitation coordinators and social insurance officers.Conclusions: Political decisions on laws and regulations for sickness certification impacted the primary health care making the physicians' work difficult and burdensome. Their views and suggestions should be carefully considered in future organization of primary care. KEY POINTSIn 2005 Swedish government introduced reforms to decrease the inequalities and costs of sickness certification and facilitate the physicians' work. Focus group interviews with Swedish primary care physicians revealed that sickness certification was challenging due to differing demands from authorities, management and patients.Coping strategies for the sick-listing task included both active measures and passive adaptation to the circumstances.A proposal for future better working conditions for physicians was to transfer lengthy sickness certifications and rehabilitation to specialized teams.

The quality of the sickness certificate. A case control study of patients with symptom and disease specific diagnoses in primary health care in Sweden.

Objective: To compare information in sickness certificates and rehabilitation activities for patients with symptom diagnoses vs patients with disease specific diagnoses. Design: Retrospective case control study 2013-2014. Setting: Primary health care, Sweden. Subjects. Patients with new onset sickness certificates with symptom diagnoses n = 222, and disease specific diagnoses (controls), n = 222. Main outcome measures: Main parameters assessed were: information about body function and activity limitation in certificates, duration of sick leave, certificate renewals by telephone, diagnostic investigations, health care utilisation, contacts between patients, rehabilitation coordinators, social insurance officers, employers and occurrence of rehabilitation plans. Results: Information about body function and activity limitation was sufficient according to guidelines in half of all certificates, less in patients with symptom diagnoses compared to controls (44% vs. 56%, p = 0.008). Patients with symptom diagnoses had shorter sick leave than controls (116 vs. 151 days p = 0.018) and more certificates issued by telephone (23% vs. 15% p = 0.038). Furthermore, they underwent more diagnostic investigations (32% vs. 18%, p < 0.001) and the year preceding sick leave they had more visits to health care (82% vs. 68%, p < 0.001), but less follow-up (16% vs. 26%, p < 0.008). In both groups contacts related to rehabilitation and with employers were scarce. Conclusion: Certificates with symptom diagnoses compared to disease specific diagnoses could be used as markers for insufficient certificate quality and for patients with higher health care utilisation. Overall, the information in half of the certificates was insufficient and early contacts with employers and rehabilitation activities were in practice missing. KEY POINTS Symptom diagnoses are proposed as markers of sickness certification quality. We investigated this by comparing certificates with and without symptom diagnoses. Certificates with symptom diagnoses lacked information to a higher degree compared to certificates with disease specific diagnoses. Regardless of diagnoses, early contacts between patients, rehabilitation coordinators and social insurance officers were rare and contacts with employers were absent.

Effect of Foot Manipulation on Pregnancy-Related Pelvic Girdle Pain: A Feasibility Study.

OBJECTIVE: The objective of this study was to investigate if the research process to evaluate the effect of foot manipulation on pregnancy-related pelvic girdle pain (PPGP) is feasible. METHODS: A randomized, single-blind (patients and evaluators) pilot trial was performed to compare foot manipulation to a comparative group at 6-weekly treatment sessions at 5 physiotherapy outpatient clinics in Skaraborg primary care (Skövde, Sweden). Women at 12 to 31 weeks of pregnancy with well-defined PPGP (n = 97) and joint dysfunction or decreased range of movement in the feet were included. Women with a twin pregnancy, low back pain, rheumatoid arthritis, or other serious diseases and those who had previous foot manipulation were excluded. Visual analog scale scores were recorded before study start, before and after each treatment session, and 3 months after delivery. RESULTS: One-hundred and two women were eligible, and 97 were included (group 1: foot manipulation, n = 47; group 2: comparative treatment, n = 50); 40 and 36 in the foot manipulation and comparative treatment groups, respectively, completed the study. The foot manipulation group had a nonsignificant pain relief score compared with that of the comparative group, which had higher pain relief scores. The difference was most pronounced at the first and second treatment sessions. A power analysis showed that at least 250 individuals would be needed in each group to confirm the effect of foot manipulation. CONCLUSIONS: This study showed that it is feasible to assess the effect of foot manipulation on PPGP in a multicenter physical therapy outpatient clinic setting. A new larger study should choose a different comparative method and test this hypothesis in a full-scale trial.

Diagnoses have the greatest impact on variation in sick-leave certification rate among primary-care patients in Sweden: A multilevel analysis including patient, physician and primary health-care centre levels.

AIMS: The aims of this study were to determine and evaluate simultaneously the importance of factors known to influence sick-leave certification such as the sick leave-related diagnoses, the patients' socio-economic status, and characteristics of the physicians. METHODS: Computerised medical records from 24 public primary health-care centres (PHCC) were used in a multilevel logistic regression analysis at three levels: patients (n=64,354; sex, age, socio-economic status, workplace factors and diagnoses), physicians (n=574; sex and level of experience) and PHCC (n=24). The variation of sick-leave certification at each level was the outcome. RESULTS: Most of the variation was attributed to the patient level and only 3.5% to the physician and 1.2% to the PHCC levels. Among the patient characteristics, psychiatric diagnoses (mostly acute stress) had the highest odds ratio (OR) for sick leave (OR=16.0; 95% confidence interval [CI] 15-17.2), followed by musculoskeletal diagnoses (OR=6.1; 95% CI 5.8-6.5). Other factors with increased OR were low education (OR=1.7; 95% CI 1.6-1.8), use of social allowance (OR=1.4; 95% CI 1.2-1.7) and certain workplaces (manufacture and health and social care). Being older was not associated with increased certified sick leave. CONCLUSIONS: The greatest variation in sick-leave certification rate was seen at the patient level, specifically psychiatric diagnoses. Socio-economic factors increasing the risk for sick-leave certification were education, social allowance and occupations in manufacture and caregiving. Understanding the impact of the different factors that influence certified sick leave is important both for targeted interventions in order to facilitate patients' return to work.

No physician gender difference in prescription of sick-leave certification: a retrospective study of the Skaraborg Primary Care Database.

OBJECTIVE: The primary objective was to investigate how physicians' gender and level of experience affects the rate and length of sick-leave certificate prescription. The secondary objective was to study the physicians' gender and professional experience in relation to the diagnoses on the certificates. DESIGN: Retrospective, cross-sectional study of computerized medical records from 24 health care centres in 2005. SETTING: Primary care in Sweden. SUBJECTS: Primary care physicians (n = 589) and patients (n = 88 780) aged 18-64 years. MAIN OUTCOME MEASURES: Rate and duration of sick leave certified by different categories of physicians and for different diagnoses and gender of patients. RESULTS: Sick leave was certified in 9.0% (musculoskeletal (3%) and psychiatric (2.3%) diagnoses were most common) of all contacts and the mean duration was 32.2 days. Overall there was no difference between male and female physicians in the sick-leave certification prescription rate (9.1% vs. 9.0%) or duration of sick leave (32.1 vs. 32.6 days). The duration of sick leave was associated with the physician's level of professional experience in general practice (GPs (Distriktläkare) 37, GP trainees (ST-läkare) 26, interns (AT-läkare) 20 and locum (vikarier) 19 days, p < 0.001). CONCLUSION: Contrary to earlier studies we found no difference in sick-leave certification prescription rate and length between male and female physicians.