Primary healthcare professionals' experiences of the sick leave process: a focus group study in Sweden

Factors associated with general practitioners' contacts with sick-listed patients' employers: A Swedish nationwide questionnaire study

Background: General practitioners' (GP) contacts with sick-listed patients' employers have been shown to be of importance for return to work. This study aimed to explore GPs' contacts with sick-listed patients' employers and factors associated with such contacts. Methods: In this cross-sectional study, 4228 GPs responded to a nationwide questionnaire about sickness certification (SC) practices. Outcomes of interest were participation in stakeholder meetings, having other contacts with employers, and satisfaction with employer contacts. Logistic regression models were used to investigate associations with factors related to the GP and the GP's workplace. Results: Among GPs, 34.8% participated in stakeholder meetings and 15.1% had other employer contacts; 39.4% had any or both of these contacts. Of GPs who had contacts with patients' employers, 65.8% were satisfied with the contacts. GPs regularly collaborating with rehabilitation coordinators had the strongest adjusted odds ratio (OR) for participating in stakeholder meetings, OR 2.72 (95% confidence interval (CI) 2.24-3.31), and having other contacts with employers, OR 3.85 (95% CI 2.85-5.21). Other factors positively associated with employer contacts were being a specialist, collaborating with other health professionals, finding employer contacts valuable, and having a joint SC routine/policy at the clinic. GPs who did not find SC problematic, had managerial support, or had enough resources for SC tasks were more likely to be satisfied with their employer contacts. Conclusions: Both physician characteristics and organizational factors had importance for GPs' contacts with sick-listed patients' employers. The findings imply that GPs' collaboration with patients' employers may be improved by interventions targeting both individual and organizational factors.

Stakeholders' experience of collaboration in the context of interdisciplinary rehabilitation for patients with chronic pain aiming at return to work

BACKGROUND AND PURPOSE

Chronic pain is a major reason for sick leave worldwide. Interdisciplinary pain rehabilitation programs (IPRPs), workplace interventions, and stakeholder collaboration may support patients in their return to work (RTW). Few studies have examined stakeholders' experiences of important components in the RTW rehabilitation process for patients with chronic pain, especially in the context of IPRP. This study explores and describes stakeholders' experiences with stakeholder collaboration and factors related to RTW for patients with chronic pain who have participated in IPRP.

METHODS

Six focus groups, three pair and four individual interviews were conducted with a total of 28 stakeholder representatives from three societal and three health care stakeholders. Data were analyzed using qualitative content analysis.

RESULTS

The participants revealed that stakeholder collaboration and a tailored RTW rehabilitation plan were important strategies although they noted that these strategies were not working sufficiently efficient as presently implemented. The different stakeholders' paradigms and organizational prerequisites were described as hindrances of such strategies and that the degree of tailoring depended on individual attitudes.

CONCLUSIONS

More knowledge transfer and flexibility, clearer responsibilities, and better coordination throughout the RTW rehabilitation process may increase the efficiency of stakeholder collaboration and support for patients.Implications for rehabilitationStakeholders need to have a close dialogue initiated before IPRP to be able to reach consensus and shared decision making in the RTW rehabilitation plan throughout the RTW rehabilitation process.Individually tailored solutions based on a thorough assessment of each patient's work ability and context are identified during IPRP and shall be included in the shared RTW rehabilitation plan.The responsibilities of the stakeholders need to be clarified and documented in the RTW rehabilitation plan.The role of RCs should be developed to improve the coordination throughout the patients' RTW rehabilitation process.

Cooperation between Public Primary Health Care and Occupational Health Care Professionals in Work Ability-Related Health Issues

Work disability creates significant expenses for nations and causes human suffering by limiting patients' lives. International studies show that to enhance recognition of and support for work disability, cooperation, mutual trust, and information exchange between public primary health care and occupational health care must be strengthened. However, little is known of how health care professionals experience this cooperation. The aim of this study was to understand how professionals experience the cooperation between public primary health care and occupational health services regarding patients' work ability. Semi-structured interviews were conducted with 29 health care professionals working in five small cities (<10,000 inhabitants) in Finland. Interviews were audio and video recorded, transcribed verbatim, and analyzed through inductive thematic analysis. Three key themes were identified from the interviews: attitudes toward the other health care sector, the exchange of information, and resources for cooperation. Professionals seem to have poor knowledge about the services available and how care is given in the other sector, appearing to lead to weak mutual trust. The public primary health care professionals especially emphasized the benefits of cooperation, but several issues were mentioned as barriers to cooperation. These results can be used when planning effective patient paths and service provisioning models.

Does a brief work-stress intervention prevent sick-leave during the following 24 months? A randomized controlled trial in Swedish primary care

BACKGROUND:

Work-related stress (WRS) presents a risk for sick leave. However, effective methods to identify people at risk for sick leave due to WRS at an early stage are lacking in primary health care.

OBJECTIVE:

To evaluate whether a systematic early identification of WRS can prevent sick leave over 24 months after the intervention.

METHODS:

Study participants (n = 132 intervention; n = 139 control) were employed, non-sick-listed persons seeking care at primary health care centres. The intervention included early identification of WRS by a validated instrument, general practitioner (GP) awareness supported by a brief training session, patients’ self-reflection by instrument completion, GP giving the patient feedback at consultation and GP identifying preventive measures. The control group received treatment as usual. Outcome data were retrieved from the Swedish Social Insurance Agency.

RESULTS:

The intervention group had less registered median sick leave days (n = 56) than the control group (n = 65) but the difference was not statistically significant.

CONCLUSIONS:

The brief intervention was not proven effective in preventing sick leave in the following 24 months compared to treatment as usual. Further research on how to identify, advice and treat those at high risk for sick leave in primary health care is needed.

Psychiatrists' Experience of Vocational Rehabilitation for Patients with Mental Illness

The aim of this study was to explore psychiatrists' experience of vocational rehabilitation for patients with mental illness. The study employed a qualitative design to explore psychiatrists' experience of vocational rehabilitation. Ten psychiatrists, five women and five men, 33-62 years of age (median 40), were interviewed. All of them worked with patients at Sahlgrenska University Hospital. The interviews were analyzed using inductive thematic analysis. All participants considered vocational rehabilitation to be of great importance for patients' well-being and health. The results were characterized by two opposite experiences: frustration and agency, these were the two main themes in the analysis. All narratives embraced both experiences, but some reflected more frustration and others more agency. In order for the psychiatrist to master the assignment, there is a need for further training and supervision. The psychiatrist's role, as well as other professional roles within the team, requires clarification, and the support from rehabilitation coordinators and occupational therapists should be enhanced. There is a need for improved cooperation with external actors.

Self-reported sick leave following a brief preventive intervention on work-related stress: a randomised controlled trial in primary health care

OBJECTIVES

To evaluate the effectiveness of a brief intervention about early identification of work-related stress combined with feedback at consultation with a general practitioner (GP) on the number of self-reported sick leave days.

DESIGN

Randomised controlled trial. Prospective analyses of self-reported sick leave data collected between November 2015 and January 2017.

SETTING

Seven primary healthcare centres in western Sweden.

PARTICIPANTS

The study included 271 employed, non-sick-listed patients aged 18-64 years seeking care for mental and/or physical health complaints. Of these, 132 patients were allocated to intervention and 139 patients to control.

INTERVENTIONS

The intervention group received a brief intervention about work-related stress, including training for GPs, screening of patients' work-related stress, feedback to patients on screening results and discussion of measures at GP consultation. The control group received treatment as usual.

OUTCOME MEASURES

The number of self-reported gross sick leave days and the number of self-reported net sick leave days, thereby also considering part-time sick leave.

RESULTS

At 6 months' follow-up, 220/271 (81%) participants were assessed, while at 12 months' follow-up, 241/271 (89%) participants were assessed. At 6-month follow-up, 59/105 (56%) in the intervention group and 61/115 (53%) in the control group reported no sick leave. At 12-month follow-up, the corresponding numbers were 61/119 (51%) and 57/122 (47%), respectively. There were no statistically significant differences between the intervention group and the control group in the median number of self-reported gross sick leave days and the median number of self-reported net sick leave days.

CONCLUSIONS

The brief intervention showed no effect on the numbers of self-reported sick leave days for patients seeking care at the primary healthcare centres. Other actions and new types of interventions need to be explored to address patients' perceiving of ill health due to work-related stress.

TRIAL REGISTRATION NUMBER

NCT02480855.

Positioning work related stress - GPs' reasoning about using the WSQ combined with feedback at consultation

BACKGROUND

General practitioners (GPs) regularly handle cases related to stress and work capacity, but often find this work difficult. However, using an assessment tool in a structured way can increase GPs' awareness of the risk for sick leave and need of referrals to preventive measures. Today there is no established methodical practice for this in primary health care. The aim of this study was to explore GPs' reasoning about using the Work Stress Questionnaire combined with feedback at consultation as an early intervention to reduce sick leave.

METHODS

A focus group study was performed with 23 GPs at six primary health care centres. The discussions were analysed based on a method by Krueger.

RESULTS

Three themes emerged. Positioning work-related stress describes the need to make fundamental standpoints on stress and how it should be handled, to make sense of their work concerning work-related stress. Making use of resources focuses on GPs performing to the best of their ability using assigned resources to treat patients with stress-related ill health, even if the resources were perceived as insufficient. Practising daily work focuses on the GPs' regular and preferred way of working set against the degree of intrusion and benefits. The two related themes making use of resources and practising daily work were mirrored through the third theme, positioning work-related stress, to form an understanding of how GPs should work with patients perceiving work-related stress.

CONCLUSIONS

The GPs own competence and tools, those of other professionals and the time allocated were seen as important when treating patients perceiving ill health due to work-related stress. When resources were insufficient though, the GPs questioned their responsibility for these patients. The results also indicate that the GPs viewed their ordinary consultative way of working as sufficient to identify these patients. The intervention was therefore not seen as useful for early treatment of patients at risk of sick leave due to work-related stress. However, prevention is an important part of the PHC's responsibility, and strategies concerning stress-related ill health therefore need to be more thoroughly formulated and incorporated.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02480855 . Registered 20 May 2015.

Assessing work capacity - reviewing the what and how of physicians' clinical practice

Background

Although a main task in the sickness certification process, physicians’ clinical practice when assessing work capacity has not been thoroughly described. Increased knowledge on the matter is needed to better understand and support the certification process. In this review, we aimed to synthesise existing qualitative evidence to provide a clearer description of the assessment of work capacity as practiced by physicians.

Method

Seven electronic databases were searched systematically for qualitative studies examining what and how physicians do when they assess work capacity. Data was analysed and integrated using thematic synthesis.

Results

Twelve articles were included. Results show that physicians seek to form a knowledge base including understanding the condition, the patient and the patient’s workplace. They consider both medical and non-medical aspects to affect work capacity. To acquire and process the information they use various skills, methods and resources. Medical competence is an important basis, but not enough. Time, trust, intuition and reasoning are also used to assess the patient’s claims and to translate the findings into a final assessment. The depth and focus of the information seeking and processing vary depending on several factors.

Conclusion

The assessment of work capacity is a complex task where physicians rely on their non-medical skills to a higher degree than in ordinary clinical work. These skills are highly relevant but need to be complemented with access to appropriate resources such as understanding of the associations between health, work and social security, enough time in daily work for the assessment and ways to better understand the patient’s work place. Also, the notion of an “objective” evaluation is questioned, calling for a greater appreciation of the complexity of the assessment and the role of professional judgement.

Collaboration in work ability assessment for sick-listed persons in primary healthcare

BACKGROUND

General practitioners (GPs) have expressed difficulties in issuing sickness certificates and problems may arise if this work is not performed in an adequate manner. There is scant knowledge about how collaboration with other professions could be organized to enhance this work.

OBJECTIVE

Evaluate the feasibility of occupational therapists (OTs) performing supplementary assessments for persons on sick leave.

METHODS

Four healthcare centres (HCs) tested a working approach intervention where sick-listed patients were offered a complementary occupational therapy assessment. The OT assessments were intended to provide useful information for GP issued extended sickness certificates. Data on sick leave, sickness certificates and patient questionnaires were collected at different HCs. Interviews were conducted with GPs and OTs and the Consolidated Framework for Implementation Research was used to analyse the intervention's implementation.

RESULTS

No major differences in the sickness certificate quality was found. Available data on sick leave increased for all HCs during the project. Not all GPs used the OT assessments, which indicates that the implementation of the intervention was insufficient.

CONCLUSION

Testing a new working approach in primary healthcare requires an implementation strategy. To improve sickness certification quality, this work needs to be prioritized as an important healthcare task.

The Work Stress Questionnaire (WSQ) - reliability and face validity among male workers

Background

The Work Stress Questionnaire (WSQ) was developed as a self-administered questionnaire with the purpose of early identification of individuals at risk of being sick-listed due to work-related stress. It has previously been tested for reliability and face validity among women with satisfying results. The aim of the study was to test reliability and face validity of the Work Stress Questionnaire (WSQ) among male workers.

Method

For testing reliability, a test-retest study was performed where 41 male workers filled out the questionnaire on two occasions at 2 weeks intervals. For evaluating face validity, seven male workers filled out the questionnaire and gave their opinions on the questions, scale steps and how the items corresponded to their perception of stress at work.

Results

The WSQ was, for all but one item, found to be stable over time. The item Supervisor considers one’s views showed a systematic disagreement, i.e. there was a change common to the group for this item. Face validity was confirmed by the male pilot group.

Conclusion

Reliability and face validity of the WSQ was found to be satisfying when used on a male population. This indicates that the questionnaire can be used also for a male target group.

Does early identification of work-related stress, combined with feedback at GP-consultation, prevent sick leave in the following 12 months? a randomized controlled trial in primary health care

Background

Experiencing work-related stress constitutes an obvious risk for becoming sick-listed. In primary health care, no established method to early identify, advise and treat people with work-related stress exists. The aim was to evaluate if the use of the Work Stress Questionnaire (WSQ) brief intervention, including feedback from the general practitioner (GP), had an impact on the level of sickness absence.

Method/design

In total 271 (intervention group, n = 132, control group, n = 139) non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers participated in this two-armed randomized controlled trial. The main outcomes were the number of registered sick leave days and episodes, and time to first sick leave during the 12-months follow-up. The intervention included early identification of work-related stress by the WSQ, GP awareness supported by a brief training session, patients’ self-reflection by WSQ completion, GP feedback at consultation, and initiation of preventive measures.

Results

The mean days registered for the WSQ intervention group and the control group were 39 and 45 gross days respectively, and 31 and 39 net days respectively (ns). No statistical significant difference for the number of sick leave episodes or time to first day of sick leave episode were found between the groups.

Conclusions

The WSQ brief intervention combined with feedback and suggestions of measures at patient–GP-consultation was not proven effective in preventing sick leave in the following 12 months compared to treatment as usual. More research is needed on methods to early identify, advise and treat people with work-related stress in primary health care, and on how and when GPs and other professionals in primary health care can be trained to understand this risk of sick leave due to work-related stress, on how to prevent it, and on how to advise and treat employees at risk.

Trial registration

ClinicalTrials.gov. Identifier: NCT02480855. Registered 20 May 2015.

Mapping Out One's Own Paths Toward Work: Focus on Experiences of Return to Work After Spinal Cord Injury

Involving persons with spinal cord injury (SCI) as experts in their lives is important for research to design relevant health care interventions. The purpose of this study was to use photovoice methods to explore experiences of barriers and possibilities in return to work among working adults with SCI. The photovoice group consisted of six persons living with SCI that met weekly over 2 months to share and discuss photos related to return to work. Five themes were identified: (a) there is only one way, (b) welcome back-or not, (c) to be like anyone else-or to be perceived as someone else, (d) friction in the absence of clarity, and (e) finding integrated strategies for everyday life with work. Work was experienced as rewarding and viable, but due to lack of societal and workplace support, a need to map out one's own paths toward work was identified.

Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders? - a comparative qualitative case study in the Scandinavian context

Background

Despite extensive publication of clinical guidelines on how to manage musculoskeletal pain and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain. Previous studies have indicated a potential for better outcomes by formalized, early referral to allied healthcare providers familiar with occupational health issues. Instances where allied healthcare providers of comparable professional characteristics, but with differing practice parameters, can highlight important social and organisational strategies useful for informing policy and practice. Currently, Norwegian chiropractors have legislated sickness certification rights, whereas their Danish and Swedish counterparts do not. Against the backdrop of legislative variation, we described, compared and contrasted the views and experiences of Scandinavian chiropractors engaging in work disability prevention and sickness absence management.

Methods

This study was embedded in a two-phased, sequential exploratory mixed-methods design. In a comparative qualitative case study design, we explored the experience of chiropractors regarding sickness absence management drawn from face-to-face, semi-structured interviews. We subsequently coded and thematically restructured their experiences and perceptions.

Results

Twelve interviews were conducted. Thematically, chiropractors' capacity to support patients in sickness absence management revolved around four key issues: issues of legislation and politics; the rationale for being a sickness absence management partner; whether an integrated sickness absence management pathway existed/could be created; and finally, the barriers to service provision for sickness absence management.

Conclusion

Allied health providers, in this instance chiropractors, with patient management expertise can fulfil a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices.

Early identification in primary health care of people at risk for sick leave due to work-related stress - study protocol of a randomized controlled trial (RCT)

BACKGROUND

Early identification of persons at risk of sickness absence due to work-related stress is a crucial problem for society in general, and primary health care in particular. Tho date, no established method to do this exists. This project's aim is to evaluate whether systematic early identification of work-related stress can prevent sickness absence. This paper presents the study design, procedure and outcome measurements, as well as allocation and baseline characteristics of the study population.

METHOD/DESIGN

The study is a two-armed randomized controlled trial with follow-up at 3, 6 and 12 months. Non-sick-listed employed women and men, aged 18 to 64 years, who had mental and physical health complaints and sought care at primary health care centers (PHCC) were eligible to participate. At baseline work-related stress was measured by the Work Stress Questionnaire (WSQ), combined with feedback at consultation, at PHCC. The preventive intervention included early identification of work-related stress by the WSQ, GP training in the use of WSQ, GP feedback at consultation and finding suitable preventive measures. A process evaluation was used to explore how to facilitate future implementation and structural use of the WSQ at the PHCC. The primary outcome to compare the preventive sick leave intervention by the general practitioner (GP) versus treatment as usual is sick leave data obtained from the Swedish Social Insurance Agency register.

DISCUSSION

Early screening for sick leave due to work-related stress makes it possible not only to identify those at risk for sick leave, but also to put focus on the patient's specific work-related stress problems, which can be helpful in finding suitable preventive measures. This study investigates if use of the WSQ by GPs at PHCCs, combined with feedback at consultation, prevents future sickness absence.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT02480855 . Registered 20 May 2015.

Registered nurses' work with sick leave questions by telephone in primary health care

AIMS AND OBJECTIVES

To describe registered nurses' work with sick leave questions by telephone.

BACKGROUND

In Sweden, when a sick person needs to request a sickness certification, it is common to contact the primary healthcare centre. The main access to primary health care is by telephone, with a registered nurse answering the care seeker's questions, triaging and helping care seekers to the right level of care. Registered nurses' work with sick leave questions has not been studied, except for two qualitative interview studies.

DESIGN

A descriptive cross-sectional study.

METHODS

A questionnaire with 120 questions was distributed to 185 registered nurses in one county in central Sweden. Descriptive statistics were used for analysis.

RESULTS

Response rate was 62% (n = 114). Registered nurses (n = 105) in this study talked weekly to persons on, or at risk, for sick leave. A large part (n = 78) felt they had a role in the care of persons on sick leave, consisting of booking appointments as well as acting as a pilot, advisor, caretaker and coordinator. For 74 of 114 registered nurses, it was problematic to handle the phone calls weekly. Measures were 'often' booking appointments with physicians (n = 67) and 'seldom' providing information on social insurance rules ('never' n = 51). The registered nurses expressed a great need for more education.

CONCLUSION

Registered nurses in this study reported having a role in the care of persons on sick leave when handling sick leave questions by telephone. The telephone calls were problematic to handle, and the registered nurses expressed a great need for education and training in social insurance medicine.

RELEVANCE TO CLINICAL PRACTICE

There is a need to educate and train registered nurses in social insurance medicine to provide high-quality nursing for patients on or at risk for sick leave.

Early and Late Return to Work After Sick Leave: Predictors in a Cohort of Sick-Listed Individuals with Common Mental Disorders

OBJECTIVES

The study aims to identify individual and workplace factors associated with early return to work (RTW)-defined as within 3 months-and factors associated with later RTW-between 3 and 12 months after being sick-listed-in a cohort of newly sick-listed individuals with common mental disorders.

METHODS

In a prospective cohort study, a cross-sectional analysis was performed on baseline measures of patients granted sick leave due to common mental disorders. A total of 533 newly sick-listed individuals fulfilled the inclusion criteria and agreed to participate. A baseline questionnaire was sent by post within 3 weeks of their first day of certified medical sickness; 354 (66%) responded. Those who were unemployed were excluded, resulting in a study population of 319 individuals. Sick leave was recorded for each individual from the Social Insurance Office during 1 year. Analyses were made with multiple Cox regression analyses.

RESULTS

Early RTW was associated with lower education, better work ability at baseline, positive expectations of treatment and low perceived interactional justice with the supervisor. RTW after 3 months was associated with a need to reduce demands at work, and turnover intentions.

CONCLUSIONS

Early RTW among sick-listed individuals with common mental disorders seems to be associated with the individual's need to secure her/his employment situation, whereas later RTW is associated with variables reflecting dissatisfaction with work conditions. No health measures were associated with RTW. The study highlights the importance of considering not only health and functioning, but also workplace conditions and relations at the workplace in implementing RTW interventions.

General practitioners and sickness certification for injury in Australia

Background

Strong evidence supports an early return to work after injury as a way to improve recovery. In Australia, General Practitioners (GPs) see about 96 % of injured workers, making them the main gatekeepers to workers’ entitlements. Most people with compensable injuries in Australia are certified as “unfit to work” by their GP, with a minority of patients certified for modified work duties. The reasons for this apparent dissonance between evidence and practice remain unexplored. Little is known about the factors that influence GP sickness certification behaviour in Australia. The aim of this study is to describe the factors influencing Australian GPs certification practice through qualitative interviews with four key stakeholders.

Methods

From September to December 2012, 93 semi-structured interviews were undertaken in Melbourne, Australia. Participants included GPs, injured workers, employers and compensation agents. Data were thematically analysed.

Results

Five themes describing factors influencing GP certification were identified: 1. Divergent stakeholder views about the GP’s role in facilitating return to work; 2. Communication between the four stakeholder groups; 3. Conflict between the stakeholder groups; 4. Allegations of GPs and injured workers misusing the compensation system and 5. The layout and content of the sickness certificate itself.

Conclusion

By exploring GP certification practice from the perspectives of four key stakeholders, this study suggests that certification is an administrative and clinical task underpinned by a host of social and systemic factors. The findings highlight opportunities such as practice guideline development and improvements to the sickness certificate itself that may be targeted to improve GP sickness certification behaviour and return to work outcomes in an Australian context.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0307-9) contains supplementary material, which is available to authorized users.

Trends of sickness certifications in primary health care in muscat, sultanate of oman

OBJECTIVES

Sickness certification (SC) is common practice in primary health care with proven implications on the health system. To assess the rate of sickness certifications in the Bowsher province and describe related demographic, occupational and medical factors.

METHODS

Our retrospective, cross-sectional study retrieved data for all consultations, with patients aged six to 65 years old, which ended with SC. The data from four primary health care centers in the Bowsher provice were collected during 2011 using the electronic medical record system. Collected data included patient demographics, occupation, date issued, duration of sickness certification, recorded vital signs, and clinical diagnosis. Suitable rates were calculated as percentages and important differences were compared using the chi-square test.

RESULTS

The total number of consultation visits for the targeted population was 189,275. Of these 26,096 consultations resulted in SC to a total of 15,758 patients. The overall rate of SC was 13.8 per 100 consultation-years (confidence interval (CI): 13.6-14). SC rates in males were significantly higher than females (17 and 11 per 100 consultations/year, respectively). Patients aged 19-29 years old had the highest rate of SC (18.6/100 consultations/year). School students aged six to 18 years made up 28% of patients, and 24% and 22% of patients were working in the private and public sectors, respectively. No vital signs record was found for 30% of SC visits. The highest rate of SC was in October (17%) and the lowest was in August (9%). Acute respiratory infections were the most frequent diagnoses (31%) resulting in certifications. The rate of SC issued for Omanis and non-Omanis was 14 and 9 per 100 consultations per year, respectively.

CONCLUSION

Sickness certification is a burden on primary health care in the studied health centers with approximately one in seven consultations ending with SC issued. More investigations are needed to identify determinates of high sickness absence. Robust guidelines are important to regulate the number of sickness certificates issued.

GPs' negotiation strategies regarding sick leave for subjective health complaints

OBJECTIVES

To explore general practitioners' (GPs') specific negotiation strategies regarding sick-leave issues with patients suffering from subjective health complaints.

DESIGN

Focus-group study.

SETTING

Nine focus-group interviews in three cities in different regions of Norway.

PARTICIPANTS

48 GPs (31 men, 17 women; age 32-65), participating in a course dealing with diagnostic practice and assessment of sickness certificates related to patients with subjective health complaints.

RESULTS

The GPs identified some specific strategies that they claimed to apply when dealing with the question of sick leave for patients with subjective health complaints. The first step would be to build an alliance with the patient by complying with the wish for sick leave, and at the same time searching for information to acquire the patient's perspective. This position would become the basis for the main goal: motivating the patient for a rapid return to work by pointing out the positive effects of staying at work, making legal and moral arguments, and warning against long-term sick leave. Additional solutions might also be applied, such as involving other stakeholders in this process to provide alternatives to sick leave.

CONCLUSIONS AND IMPLICATIONS

GPs seem to have a conscious approach to negotiations of sickness certification, as they report applying specific strategies to limit the duration of sick leave due to subjective health complaints. This give-and-take way of handling sick-leave negotiations has been suggested by others to enhance return to work, and should be further encouraged. However, specific effectiveness of this strategy is yet to be proven, and further investigation into the actual dealings between doctor and patients in these complex encounters is needed.

Costs of production loss and primary health care interventions for return-to-work of sick-listed workers in Sweden

PURPOSE

The aim of this study was to investigate, from the perspective of society, the costs of sick leave and rehabilitation of recently sick-listed workers with musculoskeletal disorders (MSD) or mental disorders (MD).

METHODS

In a prospective cohort study, 812 sick-listed workers with MSD (518) or MD (294) were included. Data on consumption of health care and production loss were collected over six months from an administrative casebook system of the health care provider. Production loss was estimated based on the number of sick-leave days. Societal costs were based on the human capital approach.

RESULTS

The mean costs of production loss per person were EUR 5978 (MSD) and EUR 6381 (MD). Health care interventions accounted for 9.3% (MSD) and 8.2% (MD) of the costs of production loss. Corresponding figures for rehabilitation activities were 3.7% (MSD) and 3.1% (MD). Health care interventions were received by about 95% in both diagnostic groups. For nearly half of the cohort, no rehabilitation intervention at all was provided.

CONCLUSIONS

Costs associated with sick leave were dominated by production loss. Resources invested in rehabilitation were small. By increasing investment in early rehabilitation, costs to society and the individual might be reduced.

IMPLICATIONS FOR REHABILITATION

Resources invested in rehabilitation for sick-listed with musculoskeletal and mental disorders in Sweden are very small in comparison with the costs of production loss. For policy makers, there may be much to gain through investments into improved rehabilitation processes for return to work. Health care professionals need to develop rehabilitative activities aiming for return to work, rather than symptoms treatment only.