Therese Ljungquist

A 3-year follow-up of a multidisciplinary rehabilitation programme for back and neck pain

&NA; The aim of the present study was to evaluate the long‐term outcome of a behavioural medicine rehabilitation programme and the outcome of its two main components, compared to a ‘treatment‐as‐usual’ control group. The study employed a 4×5 repeated‐measures design with four groups and five assessment periods during a 3‐year follow‐up. The group studied consisted of blue‐collar and service/care workers on sick leave, identified in a nationwide health insurance scheme in Sweden. After inclusion, the subjects were randomised to one of the four conditions: behaviour‐oriented physiotherapy (PT), cognitive behavioural therapy (CBT), behavioural medicine rehabilitation consisting of PT+CBT (BM) and a ‘treatment‐as‐usual’ control group (CG). Outcome variables were sick leave, early retirement and health‐related quality of life. A cost‐effectiveness analysis, comparing the programmes, was made. The results showed, consistently, the full‐time behavioural medicine programme being superior to the three other conditions. The strongest effect was found on females. Regarding sick leave, the mean difference in the per‐protocol analysis between the BM programme and the control group was 201 days, thus reducing sick leave by about two‐thirds of a working year. Rehabilitating women has a substantial impact on costs for production losses, whereas rehabilitating men seem to be effortless with no significant effect on either health or costs. In conclusion, a full‐time behavioural medicine programme is a cost‐effective method for improving health and increasing return to work in women working in blue‐collar or service/care occupations and suffering from back/neck pain.

A randomized controlled component analysis of a behavioral medicine rehabilitation program for chronic spinal pain: are the effects dependent on gender?

&NA; The aim of the present study was to evaluate the outcome of a behavioral medicine (BM) rehabilitation program and the outcome of its two main components, compared to a ‘treatment‐as‐usual’ control group (CG). The study employed a 4×4 repeated‐measures design with four groups and four assessment periods (pre‐treatment, post‐treatment, 6‐month follow‐up, and 18‐month follow‐up). The group studied consisted of subjects on sick leave identified in a nationwide health insurance scheme in Sweden. After inclusion, the subjects were randomized to one of four conditions, which were: (1) behavior‐oriented physical therapy (PT); (2) cognitive behavioral therapy (CBT); (3) BM rehabilitation consisting of PT+CBT (BM); (4) a ‘treatment‐as‐usual’ CG. The treatments were given over a period of 4 weeks, PT and CBT on a part‐time basis and BM on a full‐time basis. Outcome variables were sick leave, early retirement, and health‐related quality of life (measured using the Short Form Health Survey, SF‐36). The results showed that the risk of being granted full‐time early retirement was significantly lower for females in PT and CBT compared to the CG during the 18‐month follow‐up period. However, the total absence from work (sick listing plus early retirement) in days over the 18‐month follow‐up period was not significantly different in the CG compared to the treatments. On the SF‐36, women in CBT and BM reported a significantly better health‐related quality of life than women in the CG at the 18‐month follow‐up. No significant differences for men were found on the SF‐36 scales. In conclusion, the results revealed gender differences in the outcome of the treatments and that the components of this BM program yielded as good results as the whole program.

Physical performance tests for people with long-term spinal pain: aspects of construct validity.

OBJECTIVE The aim of this study was to investigate the construct validity of 6 physical performance tests that had already been shown to have acceptable repeatability. DESIGN Data were collected in a randomized controlled multi-centre study. SUBJECTS 126 women and 105 men sick-listed for spinal pain carried out the tests and provided personal and background data at inclusion in the study. METHODS One test measured stepping up onto and down from a stool, 2 measured lifting ability and 3 walking speed. Construct validity was examined by analysing the influence of some variables on test performance. RESULTS High-rated pain behaviour and perceived high pain intensity during testing or during the previous 4 weeks were connected with low test performance. Exercise twice a week was connected with high test performance. The test with the highest ability to detect disability in the women with lumbar pain was a lumbar lifting test, while for the men, it was a cervical lifting test. The test with the highest ability to detect disability in the participants with neck pain was the cervical lifting test in addition to a gait test with burden for the women. CONCLUSION Back pain hampered the test performance more than neck pain. Impairments and activity limitations expressed by the patient should guide the choice of test.

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.

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.

Problems experienced by gynecologists/obstetricians in sickness certification consultations

To explore frequencies and experiences with problems in sickness certification consultations among gynecologists and obstetricians in two different years.

Occupational health physicians have better work conditions for handling sickness certification compared with general practitioners: results from a nationwide survey in Sweden.

Aims: To study whether occupational health physicians (OPs) have a better work situation regarding handling of sickness certification compared with other physicians, in particular general practitioners (GPs), and to analyze associations between OPs’ experiences of assessing and providing a long-term prognosis of patients’ work capacity and some potentially interrelated factors. Methods: Answers to a nationwide survey from physicians who had sickness certification consultations at least once monthly were analyzed. Differences among OPs (n=481), GPs (n=4257) and physicians working in other clinical settings (n=9452) were estimated by chi square tests. Associations between OPs’ experiences as above and potentially interrelated factors were estimated using logistic regression analyses. Results: Among OPs, a lower proportion experienced clinical work situations related to sickness certifications as ‘very problematic’, compared with the other physicians, and especially so compared with GPs. A higher proportion of OPs also had organizational support for handling sickness certifications. For OPs, experience of sickness certification consultations as problematic once a month or less often, not experiencing sickness certification tasks as a work environment problem, and having a well-established workplace policy regarding sickness certification matters were significantly positively associated with finding assessing and providing a long-term prognosis of work capacity as ‘not at all/somewhat problematic’. Conclusions: OPs’ work situation regarding sickness certifications was favorable compared with that of other physicians, and especially compared with that of GPs. Our results underline the importance of organizational support for ensuring physicians’ experience of having professional competence in handling assessments of patients’ work capacity.

General practitioners’ use of sickness certification guidelines in Sweden at introduction and four years later: a survey study

Objective National sickness certification guidelines were introduced in Sweden in 2007, comprising both overarching and diagnoses-specific recommendations. This study aimed to investigate how general practitioners (GP) used and perceived the usefulness of these guidelines in the sickness certification process close after introduction and 4 years later. Design Two nationwide cross-sectional surveys in 2008 and 2012. Setting Swedish healthcare. Participants Physicians working in primary healthcare and having sickness certification consultations at least a few times per year (n = 4214 in 2008, and n = 4067 in 2012). Main Outcome Measures Frequency of use and perceived usefulness of the sickness certification guidelines. Results Most GPs used the guidelines at least a few times per year (in 2008 74.6%; in 2012 85.2%). In 2008, 44.1% reported a need to develop competence in using the guidelines, compared with 23.3% in 2012. Of those using the guidelines, 36.7% in 2008 and 44.6% in 2012 reported it problematic to write sickness certificates in accordance with the guidelines. Most GPs (89.2% in 2008 and 88.8% in 2012) valued the guidelines beneficial to ensure quality in sickness certification consultations. A larger proportion in 2012 compared with 2008 reported that the guidelines facilitated contacts with patients (61.2%, respectively, 55.6%), as well as with other stakeholders. Conclusions The guidelines were perceived as useful and beneficial to ensure high quality in sickness certification consultations, and facilitated contacts with patients as well as other stakeholders. In 2012, still one-fourth reported a need to develop more competence in using the sickness certification guidelines.