Britt Arrelöv

Frequency and nature of problems associated with sickness certification tasks: A cross-sectional questionnaire study of 5455 physicians

Objective. To study the frequency and nature of problems associated with physicians’ sickness certification practices. Design. Cross-sectional questionnaire study. Setting. Stockholm and Östergötland Counties in Sweden. Subjects. Physicians aged ≤64 years, n =7665, response rate 71% (n =5455). Main outcome measures. The frequency of consultations involving sickness certification, the frequency and nature of problems related to sickness certification. Results. A total of 74% (n =4019) of the respondents had consultations including sickness certification at least a few times a year. About half of these physicians had sickness certification cases at least six times a week, and 1 out of 10 (9.4%) had this more than 20 times a week. The items that the highest percentage of physicians rated as very or fairly problematic included: handling conflicts with patients over certification, assessing work ability, estimating optimal length and degree of absence, and managing prolongation of sick leave initially certified by another physician. There were large differences in frequency and nature of problems between different types of clinics/practices. General practitioners had the highest frequency of problems concerning sickness certification while the lowest was found among specialists in internal medicine and surgery. Conclusion. Sickness certification should be recognized as an important task also for physicians other than general practitioners. The physicians experienced problems with numerous tasks related to sickness certification and these varied considerably between types of clinics. The high rate of problems experienced may have consequences for the physicians’ work situation, for patients, and for society.

Dealing with sickness certification – a survey of problems and strategies among general practitioners and orthopaedic surgeons

BackgroundIn order to get sickness benefit a sick-listed person need a medical certificate issued by a physician; in Sweden after one week of self-certification. Physicians experience sick-listing tasks as problematic and conflicts may arise when patients regard themselves unable to work due to complaints that are hard to objectively verify for the physician. Most GPs and orthopaedic surgeons (OS) deal regularly with sick-listing issues in their daily practice. The aim of this study was to explore perceived problems and coping strategies related to tasks of sickness certification among general practitioners (GP) and orthopaedic surgeons (OS).MethodsA cross-sectional study about sickness certification in two Swedish counties, with 673 participating GPs and 149 OSs, who answered a comprehensive questionnaire. Frequencies together with crude and adjusted (gender and working years) Odds ratios were calculated.ResultsA majority of the GPs and OSs experienced problems in sickness certification every week. To assess the patients work ability, to handle situations when they and the patient had different opinions about the need for sickness absence, and to issue prolongation certificates when the previous was issued by another physician were reported as problematic by a majority in both groups. Both GPs and OSs prolonged sickness certifications due to waiting times in health care or at Social Insurance Office (SIO). To handle experienced problems they used different strategies; OSs issued sickness certificates without personal appointment more often than the GPs, who on the other hand reported having contact with SIO more often than the OSs. A higher rate of GPs experienced support from management and had a common strategy for handling sickness certification at the clinic than the OSs.ConclusionMost GPs and OSs handled sickness certification weekly and reported a variety of problems in relation to this task, generally GPs to a higher extent, and they used different coping strategies to handle the problems.

Use and usefulness of guidelines for sickness certification: results from a national survey of all general practitioners in Sweden

Objectives Diagnoses-specific sickness certification guidelines were recently introduced in Sweden. The aim of this study was to investigate to which extent general practitioners (GPs) used these guidelines and how useful they found them, 1 year after introduction. Design A cross-sectional questionnaire study. A comprehensive questionnaire about sickness certification practices in 2008 was sent to all physicians living and working in Sweden (n=36 898, response rate 60.6%). In all, 19.7% (n=4394) of the responders worked as GPs. Setting Primary healthcare in all Sweden. Participants The participating GPs who had consultations concerning sickness certification at least a few times a year (n=4278, 97%). Main outcome measures Descriptive statistics and prevalence ratios for the 11 questionnaire items about the use and usefulness of the sickness certification guidelines. Results A majority (76.2%) of the GPs reported that they used the guidelines. In addition, 65.4% and 43.5% of those GPs reported that the guidelines had facilitated their contacts with patients and social insurance officers, respectively. The guidelines also helped nearly one-third (31.5%) of the GPs to develop their competence and improve the quality of their management of sickness certification consultations (33.5%). About half experienced some problems when using the guidelines and 43.7% wanted better competence in using them. A larger proportion of non-specialists and of GPs with fewer sickness certification consultations had benefitted from the guidelines. Conclusions The national sickness certification guidelines implemented in Sweden were widely used by GPs already a year after introduction. Also, the GPs consider the guidelines useful in several respects, for example, in patient contacts and for competence development.

Frequency and severity of problems that general practitioners experience regarding sickness certification

Objective. Tasks involved in sickness certification constitute potential problems for physicians. The objective in this study was to obtain more detailed knowledge about the problems that general practitioners (GPs) experience in sickness certification cases, specifically regarding reasons for issuing unnecessarily long sick-leave periods. Design. A cross-sectional national questionnaire study. Setting. Primary health care in Sweden. Subjects. The 2516 general practitioners (GPs), below 65 years of age, who had consultations involving sickness certification every week. This makes it the by far largest such study worldwide. The response rate among GPs was 59.9%. Results. Once a week, half of the GPs (54.5%) found it problematic to handle sickness certification, and one-fourth (25.9%) had a patient who wanted to be sickness absent for some reason other than medical work incapacity. Issues rated as problematic by many GPs concerned assessing work capacity, prognosticating the duration of incapacity, handling situations in which the GP and the patient had different opinions on the need for sick leave, and managing the two roles as physician for the patient and medical expert in writing certificates for other authorities. Main reasons for certifying unnecessarily long sick-leave periods were long waiting times in health care and in other organizations, and younger and male GPs more often reported doing this to avoid conflicts with the patient. Conclusion. A majority of the GPs found sickness certification problematic. Most problems were related to professional competence in insurance medicine. Better possibilities to develop, maintain, and practise such professionalism are warranted.

Sickness certification as a complex professional and collaborative activity - a qualitative study

BackgroundPhysicians have an important but problematic task to issue sickness certifications. A manifold of studies have identified a wide spectrum of medical and insurance-related problems in sickness certification. Despite educational efforts aiming to improve physicians’ knowledge of social insurance medicine there are no signs of reduction of these problems. We hypothesised that the quality deficits is not only due to lack of knowledge among issuing physicians. The aim of the study was to explore physicians’ challenges when handling sickness certification in relation to their professional roles as physicians and to their interaction with different stakeholders.MethodsOne hundred seventy-seven physicians in Stockholm County, Sweden, participated in a sick-listing audit program. Participants identified challenges in handling sick-leave issues and formulated action plans for improvement. Challenges and responsible stakeholders were identified in the action plans. To deepen the understanding facilitators of the program were interviewed. A qualitative content analysis was performed exploring challenge categories and categories of stakeholders with responsibility to initiate actions to improve the quality of the sick-listing process. The challenge categories were then related by their content to professional competence roles in accord with the Canadian Medical Education Directions for Specialists (CanMEDS) framework and to the stakeholder categories.ResultsSeven categories of challenges were identified. Practitioner patient interaction, Work capacity assessment, Interaction with the Social Insurance Administration, The patient’s workplace and the labour market, Sick-listing practice, Collaboration and resource allocation within the Health Care System, Leadership and routines at the Health Care Unit. The challenges were related to all seven CanMEDS roles. Five categories of stakeholders were identified and several stakeholders were involved in each challenge category.ConclusionsPhysicians performing sickness certification tasks experience a complex variety of challenges. From physician perspective actions to handle these need to be initiated in interaction with both medical and non-medical stakeholders. The relation between the challenges and a well-established professional competence framework revealed a complex pattern. Thus, from a public health perspective, educational activities aimed to improve the sick-listing process should address all physician competences including identification and interaction with stakeholders, and not just knowledge of social insurance medicine.

Sickness certification of patients—a work environment problem among physicians?

BACKGROUND According to several studies, physicians find sickness certification of patients to be problematic, and some smaller studies suggest that this is a psychosocial work environment problem (WEP). AIMS To explore to what extent physicians experience sickness certification as a WEP and the associations of this with the type of clinic and other workplace factors. METHODS Analyses of data from a questionnaire sent to all physicians who were living and working in Sweden. The study group consisted of physicians aged <65 years who performed sickness certification tasks (SCTs). Prevalence rates (PR) and 95% confidence intervals (CI) of finding SCTs as a WEP in relation to background factors were calculated. RESULTS The response rate was 61%. The final study group consisted of 14 210 responders. Half of the physicians (50%) experienced SCTs as a WEP, and 11% found them as a WEP to a great extent. The proportion of physicians experiencing certification tasks as a WEP varied with the type of clinic and were highest in general practice (73%), orthopaedics (68%), rheumatology (67%), neurology (59%) and psychiatry (58%). Using internal medicine as a reference group, the PRs for finding SCTs as a WEP to a great extent were 4.05 (95% CI 3.23-5.09) in general practice, 2.67 (2.05-3.47) in psychiatry and 2.66 (2.04-3.47) in orthopaedics, after adjusting for educational level and frequency of sickness certification consultations. In ear, nose and throat clinics, the PR was 0.43 (0.21-0.88). CONCLUSIONS The findings underline the importance of measures to improve the work situation for physicians regarding sickness certification practices.

Psychiatrists′ work with sickness certification: frequency, experiences and severity of the certification tasks in a national survey in Sweden

BackgroundMany psychiatrists are involved in sickness certification of their patients; however, there is very limited knowledge about this aspect of their work. The objective of this study was to explore frequencies of problematic issues in the sickness certification tasks and experiences of severity regarding these problematic issues among psychiatrists.MethodsA cross-sectional nationwide questionnaire study to all physicians in Sweden. The 579 specialists in psychiatry who answered the questionnaire, were under 65 years of age, worked mainly in psychiatric care, and had consultations involving sickness certification at least once a week were included.ResultsThe frequency of problematic sickness certification consultations a few times per year or more often was considered by 87.3% of the psychiatrists; 11.7% handle such cases at least once a week. A majority (60.9%) reported ‘not having enough time with the patient’ at least once a week. The psychiatrists had access to several categories of professionals in their daily work. More than one third certified unnecessarily long sick-leave periods at least once a month due to waiting times for Social Insurance Office investigations or for treatments or investigations within health care.ConclusionThe majority found it problematic to assess the level and duration of work incapacity, but also other types of problems like unnecessarily long sick-leave periods due to different types of waiting times. The findings have implications for different kinds of organisational and managerial support and training in sickness certification issues, like guidance to assess the level and duration of work incapacity.

Health care management of sickness certification tasks: results from two surveys to physicians

BackgroundHealth care in general and physicians in particular, play an important role in patients’ sickness certification processes. However, a lack of management within health care regarding how sickness certification is carried out has been identified in Sweden. A variety of interventions to increase the quality of sickness certification were introduced by the government and County Councils. Some of these measures were specifically aimed at strengthening health care management of sickness certification; e.g. policy making and management support. The aim was to describe to what extent physicians in different medical specialties had access to a joint policy regarding sickness certification in their clinical settings and experienced management support in carrying out sickness certification.MethodA descriptive study, based on data from two cross-sectional questionnaires sent to all physicians in the Stockholm County regarding their sickness certification practice. Criteria for inclusion in this study were working in a clinical setting, being a board-certified specialist, <65 years of age, and having sickness certification consultations at least a few times a year. These criteria were met by 2497 physicians in 2004 and 2204 physicians in 2008. Proportions were calculated regarding access to policy and management support, stratified according to medical specialty.ResultsThe proportions of physicians working in clinical settings with a well-established policy regarding sickness certification were generally low both in 2004 and 2008, but varied greatly between different types of medical specialties (from 6.1% to 46.9%). Also, reports of access to substantial management support regarding sickness certification varied greatly between medical specialties (from 10.5% to 48.8%). More than one third of the physicians reported having no such management support.ConclusionsMost physicians did not work in a clinical setting with a well-established policy on sickness certification tasks, nor did they experience substantial support from their manager. The results indicate a need of strengthening health care management of sickness certification tasks in order to better support physicians in these tasks.

Reasons for and factors associated with issuing sickness certificates for longer periods than necessary: results from a nationwide survey of physicians

BackgroundPhysicians’ work with sickness certifications is an understudied field. Physicians’ experience of sickness certifying for longer periods than necessary has been previous reported. However, the extent and frequency of such sickness certification is largely unknown. The aims of this study were: a) to explore the frequency of sickness certifying for longer periods than necessary among physicians working in different clinical settings; b) to examine main reasons for issuing sickness certificates for longer periods than necessary; and c) to examine factors associated with unnecessary issued sickness certificates.MethodsIn 2008, all physicians living and working in Sweden (a total of 36,898) were sent an invitation to participate in a questionnaire study concerning their sick-listing practices. A total of 22,349 (60.6%) returned the questionnaire. In the current study, physicians reporting handling sickness certification consultations at least weekly were included in the analyses, a total of 12,348.ResultsThe proportion of physicians reporting issuing sickness certificates for longer periods than actually necessary varied greatly between different types of clinics, with the highest frequency among those working at: occupational medicine, orthopedic, primary health care, and psychiatry clinics; and lowest among those working in: eye, dermatology, ear/nose/throat, oncology, surgery, and infection clinics. Logistic analyses showed that sickness certifying for longer periods than necessary due to limitations in the health care system was particularly common among physicians working at occupational medicine, orthopedic, and primary health care clinics. Sickness certifying for longer periods than necessary due to patient-related factors was much more common among physicians working at psychiatric clinics. In addition to differences between clinics, frequency of sickness certificates issued for longer periods than necessary varied by age, physicians’ experiences of different situations, and perceived problems.ConclusionsThis study showed that physicians issued sickness certificates for longer periods than actually necessary quite frequently at some types of clinics. Differences between clinics were to a large extent associated with frequency of problems, lack of time, delicate interactions with patients, and need for more competence.

Quality of medical certificates issued in long-term sick leave or disability in relation to patient characteristics and delivery of health care

Aim: To assess the quality of medical certificates issued during long-term sick leave or disability. Methods: We collected a stratified randomised sample of 250 medical certificates issued for assessment of work capacity: Certificates issued in primary health care (PHC) with a locomotor, psychiatric or other main diagnosis, in psychiatric care, and in other secondary care. Four experts performed a quality assessment per section of the certificate and globally. Results: The certificates varied from short notes to extensive documents. Those issued in PHC included more diagnoses per certificate (p <0.0001) than in secondary care. PHC physicians had a longer professional relationship to their patients (p = 0.009). Information on work capacity was entirely adequate and relevant in only 10% of the certificates. Disturbed mental function was indicated in 60% of the certificates without psychiatric main diagnosis. Whether indicated medical state influenced functional state was not assessable in 46 (19 %) of the certificates due to lack of information. Similarly, if reduced function influenced working capacity was not assessable in 66 (27 %) of the certificates. The global quality differed (p <0.0001) between certificates issued in primary care 5.7 (CI 5.5–5.9) and secondary care 6.9 (CI 6.5–7.3). Conclusions: There is a need for improvement of the quality of medical certificates issued in cases of long-term sick leave or disability. The quality of medical certificates was low and lacked necessary information requested by the Social Insurance Agency. The quality was lower in certificates issued in primary care, which might be explained by a different case-mix.