The influence of GP and patient gender interaction on the duration of certified sickness absence

An explorative study of factors associated with treatment in specialized mental health care centers among GP patients in Norway

BACKGROUND

Effectiveness and efficiency are part of the quality of care for mental health problems, and treatment should thus be performed at the right level of care. Norwegian guidelines specify which patients should be given priority for treatment in specialized mental health care (SMHC) centers, but there is a lack of agreement on which patients should actually receive SMHC. In this study we wanted to examine what factors (patient and GP characteristics) were related to GP patients who received treatment in SMHC centers.

METHODS

In this retrospective cohort study, we looked at 12 months of data from electronic health records from six GP and SMHC centers of hospitals in the catchment area. We included all patients who had been treated at any of the GP centers during the 12-month period (N=18032). We fit a generalized linear mixed model to explore which factors were related to patients receiving treatment in SMHC centers. Further exploration was performed to study the effects of gender and contact frequency.

RESULTS

We found that 4.6% of all GP patients and 18.4% of the GP patients with a mental health problems were treated in SMHC centers. There were more women than men among the GP-patients (56% vs 44%) and in SMHC centers (55% vs 45%), women with mental health problems were more severely ill than men. However, after adjusting for other factors men were more likely to be treated in SMHC centers (OR: 1.44). Patients with frequent GP contact were more likely to be treated in SMHC centers. The GP characteristics age, gender and specialization did not relate to patients receiving treatment in SMHC centers.

CONCLUSIONS

Men were more likely to be treated in SMHC centers than women, which may imply that they have different thresholds for entering SMHC centers. GP characteristics were not related to receiving treatment in SMHC centers. More specific knowledge is needed to determine whether men and women currently receive treatment at the lowest possible level of care.

Gender difference in sickness absence: Do managers evaluate men and women differently with regard to the appropriateness of sickness absence?

Aims: Women have much higher rates of sickness absence than men, but the causes of the difference are not well understood. This study examines whether managers have more lenient attitudes towards women's than towards men's absence, as this might contribute to higher rates of sickness absence among women. Differences between managers and other employees are also assessed. Methods: Vignettes were used to measure attitudes towards the legitimacy of sickness absence. The vignettes consisted of brief case descriptions of individuals considering asking their physicians for sick leave, with information about the medical condition (mainly taken from the descriptions in ICPC-2), occupation and gender. Respondents judged how appropriate sickness absence was in each case. Quota sampling was used, and the effective sample size was 899 managers and 1396 other employees, with each respondent evaluating either four or six vignettes. Generalised ordinal logistic regression was used. Results: The gender of the vignette person had no effect on the managers' evaluations of the appropriateness of sickness absence. Irrespective of the gender of the vignette person, however, managers were generally more restrictive than non-managers. Conclusions: Different attitudes on the part of managers towards sickness absence in men and women do not seem to contribute to gender differences in sickness absence, but managers are generally more restrictive compared to non-managerial employees.

Affecting patients with work-related problems by educational training of their GPs: a cost-effectiveness study

Background

Assessing the cost effectiveness of training aimed at increasing general practitioners’ (GP) work awareness and patients’ work-related self-efficacy and quality of life.

Methods

A cluster randomized controlled trial in twenty-six GP practices in the southeast of the Netherlands with 32 participating GPs. GPs working in an intervention group practice received training and GPs working in a control group practice delivered usual care. The training intervention consisted of lectures and workshops aimed at increasing GPs’ work awareness and more proactive counseling for patients with work-related problems (WRP). Subjects were working age patients with paid work for at least 12 h per week, who visited one of the participating GPs during the study period. As outcome measures we used the Return to Work Self Efficacy scale to assess patients’ work-related self-efficacy and the Euroquol to assess quality of life. We also measured health care costs and productivity costs. With a 4-item questionnaire we asked patients to assess their GPs’ work awareness. Data were collected at baseline, after 6 and 12 months.

Results

Data of 280 patients could be analyzed. The patient related outcomes did not improve after GP training. The change in GP work awareness and the overall mean cost difference (of €770) in favor of the intervention group were not significant.

Conclusions

The training intervention presented in this paper was not cost-effective. Training which is further personalized and targeted at high risk groups with respect to WRP, is more likely to be cost effective.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0924-9) contains supplementary material, which is available to authorized users.

The issue of "long-term" fit notes for depression in the UK: patient, GP and general practice variation

Background: Depression is an important cause of certified sickness absence in the UK. It is not known what factors are associated with variation in length of sickness certificates issued by the GP to the depressed patient.Aims: The purpose of the study was to identify patient, GP and practice factors associated with the issue of a long-term (> 4 week) fit note for depression.Methods: Sixty-eight UK general practices collected sickness certification data for 12 months.Results: Over 35% of 8127 fit notes issued to 3361 patients for depression were classed as long-term (over four weeks in duration). Having previous fit notes for depression, not having "may be fit" advice on the fit note, older patient age, the patient living in a deprived neighbourhood and a higher practice deprivation status were all significant predictors of a long-term fit note. Depression fit notes issued by female GPs to female patients were less likely to be long-term. Other GP factors were not significant predictors of a long-term depression note.Conclusions: Reducing the number of long-term sickness certificates issued to people with depression should be considered part of return-to work and job retention strategies.

Should General Practitioners Issue a Sick Certificate to Employees Who Consult for Low Back Pain in Primary Care?

PURPOSE

Back pain is a common problem and has significant societal impact. Sickness certification is commonly issued to patients consulting their general practitioner with low back pain. The aim of this study was to investigate the association of certification for low back pain with clinical outcomes and cost consequences.

METHODS

A prospective cohort study using linked questionnaire and medical record data from 806 low back pain patients in 8 UK general practices: comparison of 116 (14.4%) who received a sickness certificate versus 690 who did not receive certification. The primary clinical measure was the Roland and Morris Disability Questionnaire (RMDQ). Data on back pain consultation and work absenteeism were used to calculate healthcare and societal costs.

RESULTS

Participants issued a sickness certificate had higher back-related disability at baseline consultation and 6-month follow-up [mean difference 3.1 (95% CI 1.8, 4.4) on the RMDQ], indicating worse health status. After fully adjusting for baseline differences, most changes in clinical outcomes at 6 months were not significantly different between study groups. Productivity losses were significantly higher for the certification group, with most absence occurring after the expected end of certification; mean difference in costs due to absenteeism over 6 months was £1,956 (95% CI £941, £3040).

CONCLUSIONS

There was no clear evidence of a difference in clinical outcomes between individuals issued a sickness certificate and those not issued a certification for their back pain. With little overall contrast in clinical outcomes, policy makers and care providers may wish to draw on the likely difference in societal costs alongside issues in ethical and moral care in their consideration of patient care for low back pain.

The influence of prior training on GPs’ attitudes to sickness absence certification post-fit note

Aim

To investigate the attitudes to health and work of general practitioners (GPs) with training in occupational medicine (OM) compared with non-OM trained GPs, since the introduction of the fit note.

Background

Changes to the UK sickness certification system since 2010 and the introduction of the fit note required GPs to change their focus to what patients can do, rather than what they cannot do in relation to work. In an effort to reduce the UK sickness absence burden, GPs completion of the fit note should help to keep people in work, or assist patients to return to work as quickly as possible after a period of absence.

Methods

Questionnaire data were collected via the 7th National General Practitioner Worklife Survey.

Findings

Results indicate that responses from GPs who had undertaken training in OM, and GPs having received some form of work and health training in the 12-month period before the study were associated with significantly more positive attitudes to patients’ returning to work and to the fit note. This study reveals evidence of a difference between trained and non-trained GPs in their attitude to the fit note, and to work and health generally. Further work investigating the effect of specific training in OM on the management and recognition of ill-health by GPs is recommended.

Trends in sickness certification of injured workers by general practitioners in Victoria, Australia

BACKGROUND

General practitioners (GPs) play a critical role in facilitating injured workers return to work via their ability to certify capacity to return to employment. However, little is known about the sickness certification patterns of GPs in the context of workers' compensation claims.

AIM

To determine if GPs' sickness certification behaviour has changed between 2003 and 2010 in Victoria, Australia.

METHOD

Retrospective population-based cohort study of all injured workers with an accepted compensation claim. Sickness certification rates per 1,000 working population per annum were calculated. General regression models adjusted for workers' age and annual claim number were fitted to summarize changes in count and duration (expressed as incidence rate ratios or IRRs) of unfit for work (UFW) versus alternate duties (ALT) certificates within six categories of work-related injury and disease.

RESULTS

92,134 UFW and 28,293 ALT certificates were identified. A significant decrease in the unadjusted annual certification rates per 1,000 working population was observed. However, after adjusting for the annual number of claims and age, the IRRs of certificates increased over time. The rate of injuries and IRRs of certificates varied across affliction categories, IRRs being higher in mental health conditions in women than in men (IRR: 0.40, 95 % CI 0.38-0.41 vs. IRR: 0.17, 95 % CI 0.16-0.18). The duration of certificates remained stable, with the ALT being longer than UFW certificates in all claimants.

CONCLUSION

Our findings indicate that GPs in Victoria issue an increasing number of UFW sickness certificates each year. Further research is required to investigate the reasons for such practises.

Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service

This study sought to investigate frontline mental health professionals' perceptions of work stress and the rewards and demands associated with their work. Locally known as 'linkworkers', and from a variety of professional backgrounds, these staff worked mainly in general practice settings. Individual interviews were conducted with nine linkworkers, and the interview transcripts were analysed thematically. The main themes identified were the following: demands, coping, individual resilience, ownership and creativity, boundaries, secure base and service philosophy and ethos. Themes, categories and sub categories were presented and discussed with seven of the linkworkers in two focus groups. Focus group transcripts were analysed, and additional themes of recognizing limitations, disillusionment and the dilemma of setting boundaries were identified. These themes overlapped with those previously identified but were associated with service changes over time. The themes of ownership and creativity and service philosophy and ethos are significant, not only in relation to their impact on individual linkworkers but also in terms of their relevance for establishing and maintaining morale, engagement and a reflective culture within a service. The relevance of this work to accessible and newly developing mental health services is considered.

KEY PRACTITIONER MESSAGE

Supporting and listening to staff and allowing time for informal contact are valued by staff and enable the provision of empathic, compassionate services. Without space for reflection, staff groups may be vulnerable to the development and effects of unhelpful organizational defences, which reduce the effectiveness, quality and efficiency of caring services and increase perceived workplace stress. Services which foster staff engagement, ownership and creativity and employ "bottom up" approaches to service development are valued by staff and appear to increase staff morale and capacity to cope adaptively to change.

Can self-reported disability assessment behaviour of insurance physicians be explained? Applying the ASE model

Background

Very little is known about the attitudes and views that might underlie and explain the variation in occupational disability assessment behaviour between insurance physicians. In an earlier study we presented an adjusted ASE model (Attitude, Social norm, Self-efficacy) to identify the determinants of the disability assessment behaviour among insurance physicians. The research question of this study is how Attitude, Social norm, Self-efficacy and Intention shape the behaviour that insurance physicians themselves report with regard to the process (Behaviour: process) and content of the assessment (Behaviour: assessment) while taking account of Knowledge and Barriers.

Methods

This study was based on 231 questionnaires filled in by insurance physicians, resulting into 48 scales and dimension scores. The number of variables was reduced by a separate estimation of each of the theoretical ASE constructs as a latent variable in a measurement model. The saved factor scores of these latent variables were treated as observed variables when we estimated a path model with Lisrel to confirm the ASE model. We estimated latent ASE constructs for most of the assigned scales and dimensions. All could be described and interpreted. We used these constructs to build a path model that showed a good fit.

Results

Contrary to our initial expectations, we did not find direct effects for Attitude on Intention and for Intention on self reported assessment behaviour in the model. This may well have been due to the operationalization of the concept of 'Intention'. We did, however, find that Attitude had a positive direct effect on Behaviour: process and Behaviour: Assessment and that Intention had a negative direct effect on Behaviour: process.

Conclusion

A path model pointed to the existence of relationships between Attitude on the one hand and self-reported behaviour by insurance physicians with regard to process and content of occupational disability assessments on the other hand. In addition, Intention was only related to the self reported behaviour with regard to the process of occupational disability assessments. These findings provide some evidence of the relevance of the ASE model in this setting. Further research is needed to determine whether the ASE variables measured for insurance physicians are related to the real practice outcomes of occupational disability assessments.

The development of instruments to measure the work disability assessment behaviour of insurance physicians

Background

Variation in assessments is a universal given, and work disability assessments by insurance physicians are no exception. Little is known about the considerations and views of insurance physicians that may partly explain such variation. On the basis of the Attitude - Social norm - self Efficacy (ASE) model, we have developed measurement instruments for assessment behaviour and its determinants.

Methods

Based on theory and interviews with insurance physicians the questionnaire included blocks of items concerning background variables, intentions, attitudes, social norms, self-efficacy, knowledge, barriers and behaviour of the insurance physicians in relation to work disability assessment issues. The responses of 231 insurance physicians were suitable for further analysis. Factor analysis and reliability analysis were used to form scale variables and homogeneity analysis was used to form dimension variables. Thus, we included 169 of the 177 original items.

Results

Factor analysis and reliability analysis yielded 29 scales with sufficient reliability. Homogeneity analysis yielded 19 dimensions. Scales and dimensions fitted with the concepts of the ASE model. We slightly modified the ASE model by dividing behaviour into two blocks: behaviour that reflects the assessment process and behaviour that reflects assessment behaviour.

The picture that emerged from the descriptive results was of a group of physicians who were motivated in their job and positive about the Dutch social security system in general. However, only half of them had a positive opinion about the Dutch Work and Income (Capacity for Work) Act (WIA). They also reported serious barriers, the most common of which was work pressure. Finally, 73% of the insurance physicians described the majority of their cases as 'difficult'.

Conclusions

The scales and dimensions developed appear to be valid and offer a promising basis for future research. The results suggest that the underlying ASE model, in modified form, is suitable for describing the assessment behaviour of insurance physicians and the determinants of this behaviour. The next step in this line of research should be to validate the model using structural equation modelling. Finally, the predictive value should be tested in relation to outcome measurements of work disability assessments.

Work-related sickness absence negotiations: GPs' qualitative perspectives

BACKGROUND

GPs can find their role as issuers of sickness certification problematic, particularly in trying to maintain a balance between certifying absence and preserving the doctor-patient relationship. Little research has been published on consultations in which sickness absence has been certified.

AIM

To explore negotiations between GPs and patients in sickness absence certification, including how occupational health training may affect this process.

METHOD

A qualitative study was undertaken with GPs trained in occupational health who also participate in a UK wide surveillance scheme studying work-related ill-health. Telephone interviews were conducted with 31 GPs who had reported cases with associated sickness absence.

RESULTS

Work-related sickness absence and patients' requests for a 'sick note' vary by diagnosis. Some GPs felt their role as patient advocate was of utmost importance, and issue certificates on a patient's request, whereas others offer more resistance through a greater understanding of issues surrounding work and health acquired through occupational health training. GPs felt that their training helped them to challenge beliefs about absence from work being beneficial to patients experiencing ill-health; they felt better equipped to consider patients' fitness for work, and issued fewer certificates as a result of this.

CONCLUSION

Complex issues surround GPs' role in the sickness-certification process, particularly when determining the patient's ability to work while maintaining a healthy doctor-patient relationship. This study demonstrates the potential impact of occupational health training for GPs, particularly in light of changes to the medical statement introduced in 2010.

Sickness-certification practice in different clinical settings; a survey of all physicians in a country

BACKGROUND

How physicians handle sickness-certification is essential in the sickness-absence process. Few studies have focused this task of physicians' daily work. Most previous studies have only included general practitioners. However, a previous study indicated that this is a common task also among other physicians. The aim of this study was to gain detailed knowledge about physicians' work with sickness-certification and of the problems they experience in this work.

METHODS

A comprehensive questionnaire regarding sickness-certification practice was sent home to all physicians living and working in Sweden (N = 36,898; response rate: 61%). This study included physicians aged <65 years who had sickness-certification consultations at least a few times a year (n = 14,210). Descriptive statistics were calculated and odds ratios (OR) with 95 % confidence intervals (CI) were estimated for having different types of related problems, stratified on clinical settings, using physicians working in internal medicine as reference group.

RESULTS

Sickness-certification consultations were frequent; 67% of all physicians had such, and of those, 83% had that at least once a week. The proportion who had such consultations >5 times a week varied between clinical settings; from 3% in dermatology to 79% in orthopaedics; and was 43% in primary health care. The OR for finding sickness-certification tasks problematic was highest among the physicians working in primary health care (OR 3.3; CI 2.9-3.7) and rheumatology clinics (OR 2.6; CI 1.9-3.5). About 60% found it problematic to assess patients' work capacity and to provide a prognosis regarding the duration of work incapacity.

CONCLUSIONS

So far, most interventions regarding physicians' sickness-certification practices have been targeted towards primary health care and general practitioners. Our results indicate that the ORs for finding these tasks problematic were highest in primary health care. Nevertheless, physicians in some other clinical settings more often have such consultations and many of them also find these tasks problematic, e.g. in rheumatology, neurology, psychiatry, and orthopaedic clinics. Thus, the results indicate that much can be gained through focusing on physicians in other types of clinics as well, when planning interventions to improve sickness-certification practice.

Victims of assault: a Europe-wide review of procedures for evaluating the seriousness of injuries

In France, victims of assault receive a medical certificate describing their injuries. This certificate must fulfil certain criteria because it plays a major role in the subsequent judicial proceedings--notably the establishment of a period of 'total incapacity for work', which determines the court in which the case will be heard. Determination of the duration of this period of incapacity is complex. We decided to review medical examination procedures for victims of assault in a number of other European countries (England and Wales, Belgium, Germany, Switzerland and Spain). Our study revealed that only in France do physicians have to make a quantitative assessment of injuries, which is supposed to reflect the extent of the injuries and the intensity of the violence--despite the difficulties this may pose. We discuss the relevance of this quantitative assessment.

Sickness certification and the GP: what really happens in practice?

BACKGROUND

GPs typically sanction absence from work by issuing sickness certificates. There has been some debate recently about changing the way sickness certificates are issued and by whom. However, without understanding GPs' certification practices, their requirements in terms of training and education and how they feel the certification process should or should not be changed, measures aimed at improving the system are unlikely to succeed.

OBJECTIVE

To investigate and describe British GPs' sickness certification practices.

METHODS

A cross-sectional nationwide postal survey of 2154 UK GPs was conducted. GPs were asked about perceived certification practices, training in sickness certification, their opinions about the certification process and potential to improve the system.

RESULTS

Adjusted response was 42% (n = 878). GPs do ask about a patient's work situation but lack training in sickness certification. GPs would like to maintain their role in sickness certification but felt there was scope for other health professionals to issue some sickness certificates. GPs report more frequent sickness certification for mental health and musculoskeletal conditions compared to any other condition.

CONCLUSIONS

This study has highlighted the main issues that GPs face during a consultation where sickness certification is a possible outcome. Lack of training in certification was a recurrent theme. However, GPs felt there was scope to improve training and recommendations were made as to how this might be achieved. The survey has highlighted that GPs feel there are opportunities to improve the system and that other health professionals may play a role in the certification process.

Does variation in general practitioner (GP) practice matter for the length of sick leave? A multilevel analysis based on Norwegian GP-patient data

In Norway, as in many countries, the national insurance system is under economic stress from demographic change impacting on the pensions versus contributions balance, and an increasing number of disability and sickness benefit claimants. The general practitioner (GP) is responsible for assessing work capacity and issuing certificates for sick leave based on an evaluation of the patient. Although many studies have analyzed certified sickness absence and predictive factors, no studies assess its variation between patients, GPs or geographical areas within a multilevel framework. Using a rich Norwegian matched patient-GP data set and employing a multilevel random intercept model, the study attempts to disentangle patient, GP and municipality-level variation in the certified sickness absence length for Norwegian workers in 2003. We find that most observed patient and GP characteristics are significantly associated with the length of sick leave (LSL) and medical diagnosis is an important observed factor explaining certified sickness durations. However, 98% of the unexplained variation in the LSL is attributed to patient factors rather than influenced by variation in GP practice or differences in municipality-level characteristics. Our findings indicate that GPs practice variation does not matter much for the patients' LSL. Our results are compatible with a high degree of patient involvement in current general practice. Based on this understanding one may infer that GPs play an advocate role for their patients in Norway, where the patients' own wishes are important when decisions are made.

Identification of UK sickness certification rates, standardised for age and sex

BACKGROUND

There is growing interest in tackling the perceived 'sick note' culture in the UK.

AIM

The aim of this paper was to report the rates of sickness certification in a UK population, using sick certification rates as a precursor to addressing fitness for work.

METHOD

Electronic records from all 14 practices included in the Keele GP Research Network were reviewed; all sickness certification records from 2005 were retrieved and corresponding consultation records were examined. Participants were 148 176 patients registered during 2005, including 6398 patients who received at least one sickness certificate during the same year.

RESULTS

The rate of sickness certification was 101.67 certificates per 1000 person years (95% confidence interval [CI] = 100.13 to 103.21). This rate was significantly higher in women, at 109.76 certificates per 1000 person years (95% CI = 107.550 to 112.02), compared to men who had a rate of 93.68 certificates per 1000 person years (95% CI = 91.59 to 95.78; P<0.001). The rate of sickness certification was greatest for mental health conditions, followed closely by musculoskeletal conditions.

CONCLUSION

On average, one in 10 patients will receive a sickness certificate each year, with the highest rates occurring around 50 years of age, in women. Mental health and musculoskeletal conditions were associated with the highest rates of certification. These results provide important information to underpin the national 'Fit for Work' scheme, by providing targets for intervention and a benchmark against which the impact of public health initiatives to reduce certified sickness absence due to health conditions can be evaluated and monitored.

Detection and prevalence of abuse of older males: perspectives from family practice

Family doctors' frequent contact with seniors put them in reasonable positions to detect elder abuse and initiate referral to adult protective services. Since doctor reporting is low, however, this paper explores whether the gender of patient and/or doctor impacts on identification of elder mistreatment, or creates differential detection of one gender over the other. Use of the validated Elder Abuse Suspicion Index (EASI), and a structured social work evaluation, is described to provide some gender-based data from Canadian family practice. Specifically, while the prevalence of elder abuse is estimated to range from 12.0% to 13.3%, the specific prevalence was found for females to be 13.6% to 15.2% and for males 9.1% to 9.7%.