Assessment of sickness certification and concepts of musculoskeletal disease and illness in the general population

How primary health care physicians make sick listing decisions: the impact of medical factors and functioning

BACKGROUND

The decision to issue sickness certification in Sweden for a patient should be based on the physician's assessment of the reduction of the patient's work capacity due to a disease or injury, not on psychosocial factors, in spite of the fact that they are known as risk factors for sickness absence. The aim of this study was to investigate the influence of medical factors and functioning on sick listing probability.

METHODS

Four hundred and seventy-four patient-physician consultations, where sick listing could be an option, in general practice in Orebro county, central Sweden, were documented using physician and patient questionnaires. Information sought was the physicians' assessments of causes and consequences of the patients' complaints, potential to recover, diagnoses and prescriptions on sick leave, and the patients' view of their family and work situation and functioning as well as data on the patients' former and present health situation. The outcome measure was whether or not a sickness certificate was issued. Multivariate analyses were performed.

RESULTS

Complaints entirely or mainly somatic as assessed by the physician decreased the risk of sick listing, and complaints resulting in severe limitation of occupational work capacity, as assessed by the patient as well as the physician, increased the risk of sick listing, as did appointments for locomotor complaints. The results for patients with infectious diseases or musculoskeletal diseases were partly similar to those for all diseases.

CONCLUSION

The strongest predictors for sickness certification were patient's and GP's assessment of reduced work capacity, with a striking concordance between physician and patient on this assessment. When patient's complaints were judged to be non-somatic the risk of sickness certification was enhanced.

Employer, insurance, and health system response to long-term sick leave in the public sector: policy implications

This study has been conducted to describe the situation of long-term sick-listed persons employed in the public sector regarding the medical reasons of their sick leave, the duration of their problems, the duration of the actual sick leave, rehabilitation support, rehabilitation measures, and the persons expectations of the future. Response rate of a postal questionnaire, where 484 women and 51 men on long-term sick leave answered, was 69%. The study-group consisted of 90% women with a median age of 50 years. The most common reasons for sick listing were long-lasting musculoskeletal problems, especially neck/shoulder pain, low back pain and osteoarthritis or other joint problems and mental problems, especially depression and burn-out syndromes. Forty-seven procent of the men and 57% of the women had been on the sick list for more than a year. Only half of them had been subjected to the legally required rehabilitation investigation of the employer This half got access to rehabilitation programs and/or vocational rehabilitation to a greater extent than those who not had been subjected to rehabilitation investigation. Less than half had been in contact with the workplace-connected rehabilitation actors, the Occupational Health Service or the Trade Union. In spite of this the sick-listed persons had a positive view of their future return to work. For long-term sick-listed persons in the public sector, there is a great potential for improvements of the rehabilitation at the workplace arena, in the involvement and cooperation between the already existing rehabilitation actors, in order to promote return to work.

Sick leave certification: an unwelcome administrative burden for the family doctor? The role of sickness certification in Maltese family practice

INTRODUCTION

In Malta, sickness certificates are needed from the first day of illness, and are issued by family doctors (FDs) either employed in the government primary healthcare system, or self-employed in private practice, or employed directly by an employer for this purpose alone. Patients visiting self-employed FDs pay directly, and are not reimbursed unless privately insured. We aimed to contribute to the discussion on the impact of sickness certification in family practice by studying the phenomenon using electronic data from an electronic patient record (EPR) used by self-employed FDs. We used this data to study the frequency of sickness certification and the relationship between the patient's reason for encounter, with or without a formal request for a certificate, and the doctor's diagnosis and certification practice.

METHODS

We used data collected by FDs in day-to-day private family practice using an episode-oriented EPR. The EPR database included all encounters in all episodes of care over a period of one year (1 January to 31 December 2001) documented by ten self-employed FDs, comprehensively coded with ICPC-2-E (Electronic Version of the International Classification of Primary Care, version 2).

RESULTS

The EPR database documented care for 7497 patients (45.4% male) over one year. During 15,781 encounters, sickness certificates were issued in 11.3% of 16,319 episodes of care. 5.7% of the reasons for encounter presented by the patient in new episodes were requests for administrative procedures, and this request was made in 8.2% of all new episodes of care.

CONCLUSION

The distribution of morbidity seen by the FDs appeared to be very wide, with a dominance of acute respiratory, gastrointestinal and musculoskeletal symptoms and diagnoses, and the role of sickness certification was quite important. The frequency of sick leave certification in Malta is comparable with that in other European countries, but the average duration of episodes is shorter. Just over 11% of private FD encounters involve issuing a sickness certificate. The high proportion of reasons for encounter formulated as a request for a sickness certificate suggests that the active role of FDs in this form of social security in the Maltese population has supported the local development of family practice.

Effects of a multidisciplinary rehabilitation programme on health-related quality of life in patients with prolonged musculoskeletal disorders: a 6-month follow-up of a prospective controlled study

PURPOSE

The aim of this prospective, controlled, follow-up study (6 months) was to examine the effects of a multidisciplinary rehabilitation programme on perceived health-related quality of life (HRQL) in patients with prolonged musculoskeletal disorders (PMSD). The programme focused on body awareness therapy and cognitive and relaxation treatment.

METHOD

The rehabilitation group comprised 122 patients, and there were 114 patients in the matched control group (CG). Both groups of patients had access to primary health care. Baseline data were compared with 6-month follow-up data within and between the groups. The following measurements were employed: HRQL (Nottingham Health Profile), body awareness, postural control, pain (VAS), pain-related medicine consumption, isometric arm muscle endurance, aerobic capacity, psychosomatic symptoms, physical and psychosocial working environment and sick leave.

RESULTS

Variables that improved significantly as compared with the CG were: HRQL, anxiety, pain related to movements, psychosomatic symptoms and need for pain-related medicines.

CONCLUSIONS

The multidisciplinary rehabilitation programme used here improved HRQL in patients with PMSD to a greater extent than the standard treatment provided within primary heath care (p = 0.01) at least in the short term.

Musculoskeletal pain: concepts of disease, illness, and sickness certification in health professionals in Norway

Concepts of disease, illness (being ill), and criteria for issuing sickness certificate for musculoskeletal pain have been investigated by a postal survey based on case histories. Questionnaires were filled in by 898 individuals; 194 General Practitioners, 76 medical consultants working for the National Insurance Administration, 307 insurance clerks, and a representative sample (N = 321) of the general public. The concepts disease and illness are meaningful and used consistently by medical doctors for infectious disease and somatic problems. Discrepancies between the medical profession representatives and the general public were, in general, attributable to differences in information and knowledge about these somatic conditions. However, for musculoskeletal pain all groups had conceptual problems. In particular, there was a lack of consensus for issuing sickness certificates. For musculoskeletal pain conditions the doctors, as a group, seemed to score at random or 50-50 level for sickness certification. All groups, including medical doctors, were reluctant to accept depression and social problems as diseases, or to accept social problems as reasons for sickness certification. The decision criteria should be identified and systematized in order to establish whether it is possible to reach a consensus for subjective complaints.