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Svanholm F, Björk M, Löfgren M, Gerdle B, Hedevik H, Molander P. Work Interventions Within Interdisciplinary Pain Rehabilitation Programs (IPRP) - Frequency, Patient Characteristics, and Association with Self-Rated Work Ability. J Pain Res 2023; 16:421-436. [PMID: 36820016 PMCID: PMC9938662 DOI: 10.2147/jpr.s390747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/17/2023] [Indexed: 02/16/2023] Open
Abstract
Background Interdisciplinary pain rehabilitation programs (IPRPs) help people with chronic pain improve their health and manage their work; however, the way IPRPs address sick leave could be improved. Although work interventions can be a part of IPRP, it is not well known how and to what extent. Aim This study explores the frequency of work interventions and the characteristics of patients who participate in work interventions as part of IPRP at specialist pain rehabilitation departments in Sweden. In addition, this study explores the association between participation in work interventions and change in patients' self-rated work ability after IPRP. Methods Data from the Swedish quality registry for pain rehabilitation (SQRP), which includes 3809 patients between 2016 and 2018, were analysed with descriptive statistics and regression analyses. Results The results indicate a high participation rate in work interventions (90%). Some differences were evident concerning characteristics of patients who participated in different work interventions. The return-to-work (RTW) plan, the most frequently used work intervention, had the strongest association with change in self-rated work ability after IPRP. However, the effect sizes were small, and the initial score best explained the change. Furthermore, there were differences between employed and unemployed patients and employment had a positive association with change in self-rated work ability. Conclusion More research is needed to understand IPRP's mechanisms and work interventions to support patients with chronic pain, reduce sick leave, and manage work. Employment status needs to be considered and interventions should be tailored to match the individual needs.
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Affiliation(s)
- Frida Svanholm
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Correspondence: Frida Svanholm, Pain and Rehabilitation Centre, County Council of Östergötland, Brigadgatan 22, Linköping, S-58185, Sweden, Tel +46 730-447785, Email
| | - Mathilda Björk
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Monika Löfgren
- Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden,Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Björn Gerdle
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Henrik Hedevik
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Peter Molander
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
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Perhoniemi R, Blomgren J. Use of Health Services and Rehabilitation before and after the Beginning of Long-Term Sickness Absence-Comparing the Use by Employment and Disability Pension Transition after the Sickness Absence in Finland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:4990. [PMID: 35564383 PMCID: PMC9099499 DOI: 10.3390/ijerph19094990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 02/01/2023]
Abstract
The objective of the study was to follow the health care and rehabilitation use before, during and after long-term sickness absence (LTSA), and to compare the use by post-LTSA labour market situation in terms of disability pension and employment. Individuals aged 18-58 with a ≥30-day LTSA spell in 2015 (N = 2427) were included from the total population of the city of Oulu, Finland. Register data included LTSA spells, outpatient health care visits, inpatient care spells and rehabilitation spells, disability pensions (DP), employment dates, and demographic, socioeconomic and disability-related covariates. The study population was followed for one year before, and three years after the start of LTSA. Negative binomial regression models were utilized to examine covariate-adjusted use of the three service types and group differences. The use of outpatient health care peaked at the start of the LTSA spell, and adjusted for covariates, the height of the peak was similar regardless of post-LTSA labour market situation. Adjusted for covariates, those who transferred to permanent DP after an LTSA used more outpatient (predicted mean 4.87 for attendance days quarterly, 95% CI 4.36-5.38) and inpatient (predicted mean 84 days quarterly, 95% CI 0.62-1.06) health care than others during three years after the start of LTSA. Individuals not employed after an LTSA showed the highest and increasing level of rehabilitation use. The results indicate that Individuals returning to employment after an LTSA are provided with relatively high amount of early outpatient care, possibly aiding the return. For individuals not employed after an LTSA, rehabilitation is used quite frequently but rather late in the disability process. The frequent use of health care among future disability pensioners is consistent with their increasing health problems leading to retirement.
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Affiliation(s)
- Riku Perhoniemi
- The Social Insurance Institution of Finland, 00250 Helsinki, Finland;
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Perhoniemi R, Blomgren J. Outpatient healthcare use before and during a long-term sickness absence spell: a register-based follow-up study comparing healthcare use by the length of sickness absence and transition to disability pension in Finland. BMJ Open 2022; 12:e053948. [PMID: 35217537 PMCID: PMC8883273 DOI: 10.1136/bmjopen-2021-053948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES The objective of the study was to examine outpatient healthcare use before and during a long-term sickness absence (LTSA), and to compare the development of healthcare use between groups defined through LTSA lengths and disability pension (DP) transition. DESIGN Register-based longitudinal study with five 6-month periods before and after the start of the LTSA spell in early 2016.LTSA groups 1 (N=210) and 2 (N=187) went on to reach the statutory maximum LTSA length, with group 1 transitioning to DP. Group 3 (N=3082) had a shorter LTSA spell. Control group 4 (N=92 921) had no LTSA. SETTING AND PARTICIPANTS Non-retired individuals aged 20-59, with no LTSA during 2015 (N=96 400) were included from the total population of the city of Oulu, Finland. Register data were linked on LTSA spells and outpatient healthcare use 2013-2018, DP status in 2018, and various covariates. MAIN OUTCOME MEASURES Negative binomial regression models were used to examine the covariate-adjusted number of healthcare visits, and to examine the association of the LTSA groups with healthcare use before and after the start of LTSA (incidence rate ratios and predicted means). RESULTS Individuals eventually reaching the maximum LTSA length (groups 1 and 2) had a higher level of healthcare use before the LTSA and especially after the start of LTSA than others. Individuals transferring to DP after the maximum LTSA (group 1) used healthcare the most after the start of LTSA. CONCLUSIONS The risk for at least 1 year's disability may be identified by frequent outpatient healthcare use years before LTSA. However, future disability retirees could not be identified through their pre-LTSA healthcare use. Instead, their high use of healthcare after the start of the LTSA was consistent with their increasing health problems leading to retirement.
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Affiliation(s)
- Riku Perhoniemi
- The Social Insurance Institution of Finland (Kela), Research Unit, Helsinki, Finland
| | - Jenni Blomgren
- The Social Insurance Institution of Finland (Kela), Research Unit, Helsinki, Finland
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Ropponen A, Narusyte J, Wang M, Kärkkäinen S, Mather L, Blom V, Bergström G, Svedberg P. Role of social benefits for future long-term sickness absence, disability pension and unemployment among individuals on sickness absence due to mental diagnoses: a competing risk approach. Int Arch Occup Environ Health 2021; 95:867-876. [PMID: 34962585 PMCID: PMC9038880 DOI: 10.1007/s00420-021-01825-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/11/2021] [Indexed: 11/17/2022]
Abstract
Purpose To investigate associations between social benefits and disability pension (DP), long-term sickness absence (LTSA, ≥ 90 days), or unemployment among Swedish twins with sickness absence (SA) due to mental diagnoses. Methods This population-based prospective twin study included register data on first incident SA spell (< 90 days) due to mental diagnoses (ICD 10 codes F00-F99) during the follow-up 2005–2016. SA < 90 days due to other diagnoses than mental diagnoses or any other social insurance benefit was identified for the preceding year of the first incident SA spell due to mental diagnoses (coded yes/no). Comparing those with any previous social benefits vs without, cumulative incidence curve to compare time to an event, and Cox proportional hazards models for cause-specific hazard ratios (HR, 95% confidence intervals, CI) treating first incident DP, LTSA and unemployment as competing risks were modeled. Results During follow-up, 21 DP, 1619 LTSA, and 808 unemployment events took place. Compared to those without, those with at least one benefit had a higher risk for DP (HR 5.03; 95%CI 1.80, 14.01), LTSA (1.67; 1.50, 1.84) and unemployment (1.24; 1.03, 1.50). The cumulative incidence for DP was very low, < 1%, for LTSA 80% with any previous social benefits vs. 60% without, and for unemployment ≤ 5%. Conclusion Social benefits received during the preceding year of SA due to mental diagnoses (< 90 days) predict DP, LTSA, and unemployment. Hence, previous social benefits may provide means for early identification of persons at risk for exit from labor market.
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Affiliation(s)
- Annina Ropponen
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden. .,Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Jurgita Narusyte
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden.,Center of Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
| | - Mo Wang
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Sanna Kärkkäinen
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden.,Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Lisa Mather
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Victoria Blom
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden.,The Swedish School of Sport and Health Sciences, Stockholm, Sweden
| | - Gunnar Bergström
- Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Occupational Health Sciences and Psychology, Centre for Musculoskeletal Research, University of Gävle, Gävle, Sweden
| | - Pia Svedberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden
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LoMartire R, Dahlström Ö, Björk M, Vixner L, Frumento P, Constan L, Gerdle B, Äng BO. Predictors of Sickness Absence in a Clinical Population With Chronic Pain. THE JOURNAL OF PAIN 2021; 22:1180-1194. [PMID: 33819574 DOI: 10.1016/j.jpain.2021.03.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 03/02/2021] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Chronic pain-related sickness absence is an enormous socioeconomic burden globally. Optimized interventions are reliant on a lucid understanding of the distribution of social insurance benefits and their predictors. This register-based observational study analyzed data for a 7-year period from a population-representative sample of 44,241 chronic pain patients eligible for interdisciplinary treatment (IDT) at specialist clinics. Sequence analysis was used to describe the sickness absence over the complete period and to separate the patients into subgroups based on their social insurance benefits over the final 2 years. The predictive performance of features from various domains was then explored with machine learning-based modeling in a nested cross-validation procedure. Our results showed that patients on sickness absence increased from 17% 5 years before to 48% at the time of the IDT assessment, and then decreased to 38% at the end of follow-up. Patients were divided into 3 classes characterized by low sickness absence, sick leave, and disability pension, with eight predictors of class membership being identified. Sickness absence history was the strongest predictor of future sickness absence, while other predictors included a 2008 policy, age, confidence in recovery, and geographical location. Information on these features could guide personalized intervention in the specialized healthcare. PERSPECTIVE: This study describes sickness absence in patients who visited a Swedish pain specialist interdisciplinary treatment clinic during the period 2005 to 2016. Predictors of future sickness absence are also identified that should be considered when adapting IDT programs to the patient's needs.
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Affiliation(s)
- Riccardo LoMartire
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; School of Health and Welfare, Dalarna University, Falun, Sweden.
| | - Örjan Dahlström
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Mathilda Björk
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Linda Vixner
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | - Lea Constan
- Department of Arts and Crafts, Konstfack: University of Arts, Crafts and Design, Stockholm, Sweden
| | - Björn Gerdle
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Björn Olov Äng
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; School of Health and Welfare, Dalarna University, Falun, Sweden; Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden
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LoMartire R, Björk M, Dahlström Ö, Constan L, Frumento P, Vixner L, Gerdle B, Äng BO. The value of interdisciplinary treatment for sickness absence in chronic pain: A nationwide register-based cohort study. Eur J Pain 2021; 25:2190-2201. [PMID: 34189810 DOI: 10.1002/ejp.1832] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Interdisciplinary treatment (IDT) is an internationally recommended intervention for chronic pain, despite inconclusive evidence of its effects on sickness absence. METHODS With data from 25,613 patients in Swedish specialist healthcare, we compared sickness absence, in the form of both sick leave and disability pensions, over a 5-year period between patients either allocated to an IDT programme or to other/no interventions (controls). To obtain population-average estimates, a Markov multistate model with theory-based inverse probability weights was used to compute both the proportion of patients on sickness absence and the total sickness absence duration. RESULTS IDT patients were more likely than controls to receive sickness absence benefits at any given time (baseline: 49% vs. 46%; 5-year follow-up: 36% vs. 35%), and thereby also had a higher total duration, with a mean (95% CI) of 67 (87, 48) more days than controls over the 5-year period. Intriguingly, sick leave was higher in IDT patients (563 [552, 573] vs. 478 [466, 490] days), whereas disability pension was higher in controls (152 [144, 160] vs. 169 [161, 178] days). CONCLUSION Although sickness absence decreased over the study period in both IDT patients and controls, we found no support for IDT decreasing sickness absence more than other/no interventions in chronic pain patients. SIGNIFICANCE In this large study of chronic pain patients in specialist healthcare, sickness absence is compared over a 5-year period between patients in an interdisciplinary treatment programme and other/no interventions. Sickness absence decreased over the study period in bothgroups; however, there was no support forthat it decreased more with interdisciplinary treatment than alternative interventions.
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Affiliation(s)
- Riccardo LoMartire
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna, Falun, Sweden
| | - Mathilda Björk
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Örjan Dahlström
- Department of Behavioural, Sciences and Learning, Linköping University, Linköping, Sweden
| | - Lea Constan
- Department of Arts and Crafts, Konstfack: University of Arts, Crafts and Design, Stockholm, Sweden
| | - Paolo Frumento
- Department of Political Sciences, University of Pisa, Pisa, Italy
| | - Linda Vixner
- School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Björn Gerdle
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Björn O Äng
- Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna, Falun, Sweden.,School of Health and Welfare, Dalarna University, Falun, Sweden
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Ropponen A, Wang M, Narusyte J, Kärkkäinen S, Blom V, Svedberg P. The role of sickness absence diagnosis for the risk of future inpatient- or specialized outpatient care in a Swedish population-based twin sample. BMC Public Health 2021; 21:957. [PMID: 34016075 PMCID: PMC8136267 DOI: 10.1186/s12889-021-10942-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Studies of consequences of sickness absence such as health and well-being have been rare whereas risk factors for sickness absence have been studied extensively. This study assumed the consequences of sickness absence would differ by diagnostic group or by patient care type. The aim was to investigate sickness absence due to various diagnosis groups as a predictor for subsequent inpatient- and specialized outpatient care while controlling for familial confounding. METHODS We utilized the register data of 69,552 twin individuals between 16 and 80 years of age (48% women). The first incident sickness absence spell, from baseline year 2005, including diagnosis of sickness absence was our primary exposure of interest and we followed them until the first incident inpatient- and specialized outpatient care episode with main diagnosis code or until 31.12.2013. RESULTS A total of 7464 incident sickness absence spells took place (11%), 42% had inpatient care and 83% specialized outpatient care (mean follow-up time 3.2 years, SD 3.1 years). All the main sickness absence diagnosis groups were associated with increased risk of future care in comparison to no sickness absence. Controlling for confounders attenuated the associations in magnitude but with retaining direction, and we could not confirm an effect of familial factors. CONCLUSIONS Sickness absence predicts both inpatient- and specialized outpatient care and the association is universal across diagnosis groups. The lower survival time and incidence rates of inpatient than specialized outpatient care point towards severity of diseases assumption. This finding was also universal across sickness absence diagnosis groups.
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Affiliation(s)
- Annina Ropponen
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Mo Wang
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Jurgita Narusyte
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden
- Center of Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
| | - Sanna Kärkkäinen
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Victoria Blom
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden
- The Swedish School of Sport and Health Sciences, Stockholm, Sweden
| | - Pia Svedberg
- Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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Ropponen A, Wang M, Narusyte J, Kärkkäinen S, Blom V, Svedberg P. The predictive role of sickness absence spell durations in associations with inpatient- and specialized outpatient care among a population-based Swedish twin sample. BMC Health Serv Res 2021; 21:315. [PMID: 33827571 PMCID: PMC8028110 DOI: 10.1186/s12913-021-06310-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/22/2021] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The associations between a sickness absence spell duration and patient care have been rarely studied. An assumption is that associations would differ by spell duration and by the patient care type, inpatient- or specialized outpatient, due to severity of diseases and/or conditions. We aimed to investigate sickness absence spells in various spell durations as a predictor for subsequent inpatient- and specialized outpatient care separately, and to study if familial confounding plays a role in these associations. METHODS We followed a population-based sample of Swedish twins born 1925-90 with national registers from 2001 for first incident sickness absence spell (days to calculate spell duration categorized into ≤30 days, 31-90 days, 91-180 days and ≥ 181 days), or no sickness absence, and for inpatient- and specialized outpatient care until 2013 (n = 24,975). Cox proportional hazards models were applied for hazard ratios (HR) with 95% confidence intervals (CI) while accounting for covariates and familial confounding. RESULTS First incident sickness absence spell across all duration categories was associated with an increased risk of inpatient- (age- and sex adjusted HR 1.28 to 6.05) or specialized outpatient care (HR 1.17-2.50), both in comparison to those without any sickness absence or the shortest sickness absence spell category (1-30 days). The associations remained statistically significant while controlling for covariates or familial confounding. CONCLUSIONS First incident sickness absence spell increases the risk of inpatient care or specialized outpatient care regardless of the duration of the sickness absence spell. Hence, incident sickness absence spells should be noted and targeted to actions at workplaces as well as in primary and occupational health care.
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Affiliation(s)
- Annina Ropponen
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden.
- Finnish Institute of Occupational Health, Helsinki, Finland.
| | - Mo Wang
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Jurgita Narusyte
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden
- Center of Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden
| | - Sanna Kärkkäinen
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden
| | - Victoria Blom
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden
- The Swedish School of Sport and Health Sciences, Stockholm, Sweden
| | - Pia Svedberg
- Department of Clinical Neuroscience, Division of Insurance Medicine, Karolinska Institutet, SE-171 77, Stockholm, Sweden
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