Christina Lindholm

A cost-effectiveness study of leg ulcer treatment in primary care: Comparison of saline-gauze and hydrocolloid treatment in a prospective, randomized study

OBJECTIVEnThe majority of leg ulcer patients in Sweden are managed by primary health care personnel. To compare, in a primary care setting, the healing results and the expenses of two commonly used wound dressings for leg ulcers.nnnDESIGNnThirty patients with leg ulcers of venous or mixed venous/arterial aetiology were randomized to treatment with saline-soaked gauze or with the hydrocolloidal dressing [HCD: DuoDERM (ConvaTec, A Bristol-Myers Squibb Company, Princeton)]. All patients were bandaged with the same compression of low-stretch-type [Comprilan (Beiersdorf AG, Hamburg)].nnnSETTINGnVårdcentralen Marieberg, Primary Health Care Centre, Motala, Sweden.nnnOUTCOME MEASURESnHealing/reduction of ulcer area, pain, costs for material, nursing time, kilometres driven were registered during a six-week period.nnnRESULTSnTwo patients dropped out of the study, one in the gauze-group due to erysipelas, and one in the HCD-group for social reasons. A total of 1234 dressing changes were analysed. Costs for material were similar in the two groups. When the total care including nursing- and travelling time and kilometres driven were analysed, the mean cost for treatment with gauze dressings was 4126 Swedish Kronor (SEK), and with HCD, 1565 SEK. Seven patients in the HCD-group and two in the gauze-group healed during the study. The reduction of the ulcer area was 19% in the gauze-group and 51% in the HCD-group (p < 0.16).nnnCONCLUSIONnThe total care, analysed in an authentic clinical setting, must be considered when different wound-care methods are discussed. In this study the use of HCD showed lower costs than use of gauze-dressings. As regards healing there was a tendency to improved healing with HCD, but no significant difference. Patients in the HCD-group reported significantly less pain at dressing changes (p < 0.003) than patients in the gauze-group.

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

BackgroundHow 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.MethodsA 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.ResultsSickness-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.ConclusionsSo 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.

Is There an Association between Long-Term Sick Leave and Disability Pension and Unemployment beyond the Effect of Health Status? – A Cohort Study

Background Studies have shown that long-term sick leave is a strong predictor of disability pension. However, few have aimed to disentangle the effect of sick leave and of health status. The objective of this study was to investigate whether there is an association between long-term sick leave and disability pension and unemployment, when taking health status into account. Methods/Principal Findings The study was based on the Stockholm Public Health Cohort, restricted to 13,027 employed individuals (45.9% men) aged 18–59 in 2002 and followed until 2007. Hazard ratios (HR) with 95% Confidence Interval (CI) were estimated by Cox regression models adjusting for socio-demographic factors and five measures of health status. Having been on long-term sick leave increased the risk of disability pension (HR 4.01; 95% CI 3.19–5.05) and long-term unemployment (HR 1.45; 95% CI 1.05–2.00), after adjustment for health status. The analyses of long-term sick leave due to specific illness showed that the increased risk for long-term unemployment was confined to the group on sick leave due to musculoskeletal (HR 1.70 95% CI 1.00–2.89) and mental illness (HR 1.80 95% CI 1.13–2.88) and further that there was an increased risk for short-term unemployment in the group on sick leave due to mental illness (HR1.57 95%CI 1.09–2.26). Conclusions/Significance Long-term sick leave increases the risks of both disability pension and unemployment even when taking health status into account. The results support the hypothesis that long-term sick leave may start a process of marginalization from the labor market.

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, 1u2005year 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=36u2008898, 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.

Prevalence of antibiotic-resistant bacteria in residents of nursing homes in a Swedish municipality: Healthcare staff knowledge of and adherence to principles of basic infection prevention

Abstract Background: The aims of this study were to investigate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in residents living in Swedish nursing homes, and if carriage of resistant bacteria was related to antibiotic treatment, other risk factors, and/or staffs adherence to guidelines for infection control. Methods: Five hundred and sixty residents from 9 nursing homes on a total of 67 wards participated in the study and had microbiological cultures taken. Faecal samples were obtained from 495 residents (88.3%). ESBL-positive residents were followed for 2 y with repeated sampling. Two hundred and ninety-six staff members were interviewed and observed regarding familiarity with and adherence to infection control guidelines. Results: No resident was positive for MRSA or VRE. Fifteen of the residents were found to be ESBL-positive. Residents living on wards where ESBL-positive residents were identified had been treated more frequently with antibiotics (42%), compared to those on wards where no residents with ESBL were found (28%; p =u20090.02). ESBL-positive Escherichia coli isolates from residents living in adjacent rooms were found to be closely genetically related when analysed by pulsed-field gel electrophoresis, indicating transmission between residents. Staff adherence to infection control guidelines sometimes revealed shortcomings, but no significant differences regarding compliance to the guidelines could be found. Conclusion: Carriage of resistant bacteria was uncommon and only ESBL-producing Enterobacteriaceae were identified in Swedish nursing homes. Usage of antibiotics was higher on wards where ESBL-positive residents were detected and there was an indication of transmission of ESBL between residents.

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.

Low level of adjustment latitude—a risk factor for sickness absence

BACKGROUNDnThe prerequisite for obtaining sickness benefit is reduced work ability for medical reasons in combination with work demands which cannot be adjusted accordingly. The aim of this study was to investigate if low levels of adjustment latitude, defined as the possibility to temporarily adjust work demands in case of ill health, influence sickness absence.nnnMETHODSnA prospective cohort study of 1420 employees (47% participation, aged 19-68; 56% women) was conducted at six Swedish workplaces. Exposure to two general and nine specific types of adjustment latitude was ascertained at baseline. Outcome was defined as the first new employer-reported sick-leave spell during a follow-up of 3-12 months. Hazard ratios (HR) of sick leave, with 95% confidence intervals (CI), were estimated by Cox proportional hazards regression.nnnRESULTSnThe incidence of sickness absence was 2.85/1000 person-days. The self-reported reasons for sick leave were mainly minor complaints such as colds, influenzas and headaches. Employees lacking adjustment latitude had an adjusted HR of sickness absence of 1.51 (95% CI 1.08-2.11). Among specific adjustment latitude types, those not having the possibility to work from home generated an HR of 1.86 (95% CI 1.31-2.64). The effects of lack of adjustment latitude were similar for men and women but seemed to vary between different occupations.nnnCONCLUSIONnA low level of adjustment latitude at work is a risk factor for sickness absence.

Prevalence of non-healed and healed chronic leg ulcers in an elderly rural population.

Scand J Prim Health Care 2000;18:58–60. ISSN 0281-3432 als who had negated present or previous leg ulceration, giving the total prevalence of 12.6%. Objecti7e – To estimate the prevalence of non-healed and healed Conclusion – The result indicates a certain risk for overestimation of chronic leg ulcers in an elderly rural population. prevalence, as well as underestimation and decreased reliability when Design – All persons 70 years or older were asked about present and basing the figures only on telephone interviews or posted questionprevious leg ulcers. naires. Setting – A rural village in mid-west Sweden with 4000 inhabitants. Participants – 541 persons aged 70 years and above.OBJECTIVEnTo estimate the prevalence of non-healed and healed chronic leg ulcers in an elderly rural population.nnnDESIGNnAll persons 70 years or older were asked about present and previous leg ulcers.nnnSETTINGnA rural village in mid-west Sweden with 4000 inhabitants.nnnPARTICIPANTSn541 persons aged 70 years and above.nnnOUTCOME MEASURESnThe prevalence of healed or non-healed chronic leg ulcers in the population aged > or = 70.nnnRESULTSnHealed or non-healed leg ulcers were reported by 53 persons (9.8%). Examination of these patients and also 100 individuals who had negated present or previous leg ulceration, giving the total prevalence of 12.6%.nnnCONCLUSIONnThe result indicates a certain risk for overestimation of prevalence, as well as underestimation and decreased reliability when basing the figures only on telephone interviews or posted questionnaires.

Development and validation of a new tool measuring nurses self-reported professional competence --the nurse professional competence (NPC) Scale

OBJECTIVESnTo develop and validate a new tool intended for measuring self-reported professional competence among both nurse students prior to graduation and among practicing nurses. The new tool is based on formal competence requirements from the Swedish Board of Health and Welfare, which in turn are based on WHO guidelines.nnnDESIGNnA methodological study including construction of a new scale and evaluation of its psychometric properties.nnnPARTICIPANTS AND SETTINGSn1086 newly graduated nurse students from 11 universities/university colleges.nnnRESULTSnThe analyses resulted in a scale named the NPC (Nurse Professional Competence) Scale, consisting of 88 items and covering eight factors: Nursing care, Value-based nursing care, Medical/technical care, Teaching/learning and support, Documentation and information technology, Legislation in nursing and safety planning, Leadership in and development of nursing care and Education and supervision of staff/students. All factors achieved Cronbachs alpha values greater than 0.70. A second-order exploratory analysis resulted in two main themes: Patient-related nursing and Nursing care organisation and development. In addition, evidence of known-group validity for the NPC Scale was obtained.nnnCONCLUSIONSnThe NPC Scale, which is based on national and international professional competence requirements for nurses, was comprehensively tested and showed satisfactory psychometrical properties. It can e.g. be used to evaluate the outcomes of nursing education programmes, to assess nurses professional competences in relation to the needs in healthcare organisations, and to tailor introduction programmes for newly employed nurses.

Short-term sick leave and future risk of sickness absence and unemployment : the impact of health status

BackgroundIn previous studies the authors have found sick leave to be a predictor of future sick leave, unemployment and disability pension. Although sick leave reflects underlying health problems, some studies have suggested that sick leave may have consequences beyond the consequences of the underlying illness. However, few studies have aimed at studying consequences of sick leave while adjusting for ill health. This study aims to explore whether short-term sick leave increases the risk of future long-term sick leave, disability pension, and unemployment. Furthermore, we aim to control for the potentially confounding effects of physical and mental health status.MethodsData were gathered from the Stockholm Public Health Cohort (SPHC), restricted to 11,156 employed individuals (48.6% men) aged 18–59, without long-term sick leave, disability pension or in-patient care the year before inclusion (2002). These were followed-up with regard to unemployment, long-term sick leave, and disability pension in 2006 and 2007.Odds ratios (OR) with corresponding 95% confidence intervals (CI) were estimated by logistic regression, controlling for six different measures of health status (limiting long-standing illness, self-rated health, mental health, somatic disease, musculoskeletal pain and in-patient care) and socio-demographic factors.ResultsResults from the unadjusted analyses indicated increased risks of long-term sick leave (OR 2.00; CI 1.62-2.46) and short-term unemployment (OR 1.76; CI 1.35-2.29) for individuals exposed to more than one short-term sick-leave spell. There were no increased odds of long-term unemployment (OR 0.54; CI 0.28-1.04) or disability pension (OR 0.72; CI 0.42-1.24). After adjusting for the different measures of health status the odds ratio for short-term unemployment was not statistically significant (OR 1.29; CI 0.97-1.74). The odds ratios for the other outcomes slightly increased after adjustment for the used measures of health status.ConclusionsThe results support the assumption that short-term sick leave may have consequences for future sick leave beyond the effect of ill health. The results point to the importance of paying attention to short-term sick leave in order to prevent subsequent sickness absence.