Sickness Certification Research Articles

Time is money: general practitioners’ reflections on the fee-for-service system

BackgroundFee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs’ reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions.MethodsWe conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis.ResultsWe identified three main themes related to GPs’ reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees.ConclusionsGPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs’ gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

BackgroundGeneral practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification.MethodsQualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke’s thematic analysis approach.ResultsOur results indicate that GPs’ sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs’ opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs’ available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence.ConclusionOur study suggests that GPs’ decisions about sickness certification is largely driven by patient preferences. The GPs’ gatekeeping function is limited to negotiations about grade and duration of absence spells.

The peritonsillar abscess and its management – is incision and drainage only a makeshift to the tonsillectomy or a permanent solution?

IntroductionThis study aims to examine the long-term management of peritonsillar abscess and compare needle aspiration, incision with drainage, and tonsillectomy in terms of comorbidities, complication rates, and recurrences in the largest study cohort published to date.MethodsWe conducted a retrospective analysis of patients, both adults and children, who were treated for peritonsillar abscess between 2007 and 2019. Patient charts were analyzed to assess surgical treatment, infection and inflammation rates, risk of bleeding, recurrence rates, duration of illness, and sick certificates. Additionally, patient imaging and blood levels were compared. Postal questionnaires were sent to all patients to evaluate subjective success rates, complications, and long-term benefits of the different treatment regimens. General practitioners and ENT doctors in private practices were contacted to gather missing data on the long-term course of the disease.ResultsA total of 821 patients with peritonsillar abscess were included in this study. Two patients had to be excluded due to incidental pathological findings. Of the remaining 819 patients, 180 were successfully treated with needle aspiration or incision. Among these patients, 37.7% required tonsillectomy during the same inpatient stay. Laboratory parameters such as leukocyte count or C-reactive protein levels were not indicative of the need for tonsillectomy. Furthermore, computed tomography was only necessary in cases of suspected parapharyngeal abscess, not in clear cases of peritonsillar abscess. Among the 641 patients who underwent tonsillectomy, 11.4% experienced postoperative bleeding requiring treatment. Only patients who underwent bilateral tonsillectomy reported recurrent episodes of sore throat and pharyngitis resulting in absence from work. The ipsilateral recurrence rate for peritonsillar abscess after needle aspiration or incision was 2.8%. There were no contralateral recurrences during the observation period.ConclusionDue to the lower risk of postoperative bleeding, shorter absence from work, and shorter inpatient stay, incision and drainage are the preferable treatment for peritonsillar abscess. Additionally, patients who underwent bilateral tonsillectomy reported higher rates of work incapacity due to sore throat caused by pharyngitis. No patient met the clear indication for bilateral tonsillectomy due to recurrent acute tonsillitis. The recurrence rate after drainage without tonsillectomy was very low (2.8% ipsilaterally, no recurrence contralaterally).

Suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. A mixed method study of GPs’ experiences

Objective To explore Norwegian GPs’ experiences with and perceived suitability of issuing sickness certifications in remote consultations during the COVID-19 pandemic. Design We used a mixed methods research design. An online survey with 301 respondents was combined with qualitative interviews with ten GPs. Setting Norwegian general practice. Results Most GPs agreed it was difficult to assess a patient’s ability to work without physical attendance for a first-time certification in remote consultations. However, extending a certification was considered less problematic. If physical examinations were required, the GPs would ask the patient to come to the office. The most suitable diagnoses for remote certification were respiratory infections and COVID-19-related diagnoses, as well as known chronic and long-term diseases. The GPs emphasized the importance of knowing both the patient and the medical problem. The GP-patient relationship could be affected by remote consultations, and there were mixed views on the impact. Many GPs found it easier to deny a request for a sickness certification in remote consultations. The GPs expressed concern about the societal costs and an increased number of certifications if remote consultations were too easily accessible. The study was conducted during the COVID-19 pandemic, and the findings should be interpreted in that context. Conclusions Our study shows that issuing sickness certifications in remote consultations were viewed to be suitable for COVID-19 related problems, for patients the GP has met before, for the follow-up of known medical problems, and the extension of sickness certifications. Not meeting the patient face-to-face may affect the GP-patient relationship as well as make the GPs’ dual role more challenging.

Physicians’ experience of and collaboration with return-to-work coordinators in healthcare: a cross-sectional study in Sweden

Purpose Return-to-work coordinators (RTWCs) give people on sick leave individualized support and coordinate between different stakeholders, including physicians. The aim of this study was to explore physicians’ experience of RTWCs and investigate factors that influence how much physicians collaborate with RTWCs, or refer patients to them, in primary, orthopaedic, and psychiatric care clinics. Materials and methods Of the 1229 physicians responding to a questionnaire, 629 physicians who had access to a RTWC in their clinic answered to questions about collaborating with RTWCs. Results Among physicians who had access to a RTWC, 29.0% collaborated with a RTWC at least once a week. Physicians with a more favourable experience of RTWCs reported more frequent collaboration (adjusted OR 2.92, 95% CI 2.06–4.15). Physicians also collaborated more often with RTWCs if they reported to often deal with problematic sick-leave cases, patients with multiple diagnoses affecting work ability, and conflicts with patients over sickness certification. Conclusions Physicians who had more problematic sick-leave cases to handle and a favourable experience of RTWCs, also reported collaborating more often with RTWCs. The results indicate that RTWCs’ facilitation of contacts with RTW stakeholders and improvements in the sickness certification process may be of importance for physicians. Implications for Rehabilitation This study of physicians’ experience of collaborating with return-to-work coordinators (RTWCs) observes that physicians reported more collaboration with or referrals to coordinators if they had a favourable experience of coordinators. The results indicate that physicians report more collaboration with or referrals to RTWCs if they had more problematic sick-leave cases to handle in the clinic. These findings imply that it might be possible to increase the collaboration between physicians and RTWCs in clinical settings by managing factors of importance.

Family physicians' sick-listing practices in relation to mental disorders: A descriptive study.

Mental disorders are among the leading causes of disability for which family physicians are often required to complete sickness certificates. Yet, little is known about family physicians' sick-listing practices in Quebec. This study aims to describe their practices, difficulties and needs. Twenty-three family physicians completed a comprehensive questionnaire on sickness certification practices. Descriptive statistics were used. Despite being completed on a weekly basis, sickness certifications were deemed problematic by all participants. While they rarely refused to sick-list a patient, 43.5% reported suggesting accommodations as an alternative to sick leave. Waiting-time to access psychotherapy and delays to set-up workplace accommodations are responsible for many unnecessary sick-leave prolongations. Lack of time, long duration absences, situations where the physician held a different opinion than the patient/healthcare provider and assessing an individual's capacity to work are the most common reported problems. More than half of participants indicated medical schools do not greatly prepare them to carry out these tasks. Sickness certifications are deemed problematic, and more training might be key. Our results can be used by medical schools or bodies responsible for continuous education to improve training.

General practitioners’ description of functioning in sickness certificates

IntroductionIn Norway, general practitioners (GPs) are the gatekeepers who provide written assessment of patients' functional ability to provide documentation for the Norwegian Labor and Welfare Administration for decisions about welfare benefits. This article investigates the description of functioning in sickness certificates according to the bio-psycho-social model described in WHO's International Classification of Functioning, Disability and Health (ICF). In particular, the study focuses on medical sick notes for young patients with common mental disorders. MethodsThis study utilized directed content analysis, where codes were defined a priori. A simplified bio-psycho-social model with ICF as a framework was used to categorize functional assessment. 393 sick notes were analyzed in Norway between January 2018–January 2020. ResultsThe results show that more than half (50.4%) of the certificates contain no information about function on any level, and that the diagnosis was the only indication of a patient's function. The biological perspective was the most common description in 39,9% of the certificates, 13,5% had a description of the patient's functioning from an individual perspective. The social perspective was only adopted in 12.0% of certificates. Only 4 certificates (1.0%) described all three perspectives (biological, individual, and social) and mentioned what the individual could do despite the illness (resources). ConclusionsWe find that information on functional ability is limited on sickness certificates in Norway. The descriptions given were mainly from the biological perspective and without social context, which is consistent with prior research.

Electronic Sick Leave Certificate on Telemedicine Service Implementation in Indonesia: A Legal Consideration

Telemedicine service has been developed in Indonesia and its use has increased during the Coronavirus Disease 2019 (Covid-19) pandemic. This service makes it easier for people to get health services without meeting face-to-face. One of them is getting electronic medical certificates i.e. sick leave. However, problems arose regarding the legitimacy of electronic sick leave certificate (e-sick leave) through telemedicine services. This study aims to analyse the legal aspects of electronic sick leave in Indonesia. This research was normative research with statue and conceptual approach. Regulations in Indonesia have not discussed in detail the provision of electronic sick leave through telemedicine services. During the Covid-19 pandemic, Indonesian Medical Council Regulation Number 74 of 2020 was issued which permitted the issuance of sick certificates in telemedicine services with due observance of the principles of caution and high accountability. However it does not regulate in detail the provision of electronic sick leave through telemedicine services. Further regulations comprising of specific requirements and procedures are needed in Indonesia regarding telemedicine services, specifically in order to have valid electronic sick leave certificate issuance that can guarantee patient safety and accountability. Technological support is also needed to support the examination of patients in telemedicine services. Issuance of electronic sick leave requires collaboration between health care facilities and companies.

The impact of clinical experience on working tasks and job-related stress: a survey among 1032 Norwegian GPs

BackgroundGeneral practice is a generalist discipline fraught with complexity. For inexperienced physicians, it may be demanding to get to grips with the clinical challenges. The purpose of this article is to describe possible differences in the range of tasks between inexperienced and experienced general practitioners (GPs), and the extent to which clinical experience affects the way in which GPs perceive their daily work.MethodsAn online questionnaire was sent to all regular GPs in Norway (N = 4784) in 2018. The study sought to document the tasks performed during a typical working day and how the GPs perceived their working situation. In this study, we compare the tasks, working situation and occurrence of potentially conflictual consultations among ‘less experienced physicians’ (≤ 5 years of experience in general practice) versus ‘more experienced physicians’ (> 5 years of experience). The findings are discussed in light of theories on development of expertise.ResultsWe received responses from 1032 GPs; 296 (29%) were less experienced and 735 (71%) more experienced. The two groups reported virtually the same number of consultations (19.2 vs. 20.5) and clinical problems handled (40.4 vs. 44.2) during the study day. The less experienced physicians reported a higher proportion of challenging and/or conflictual consultations, involving prescriptions for potentially addictive medication (5.7% vs. 3.1%), sickness certification (4.1% vs. 2.4%) and referral for medical investigations on weak clinical indication (8.1% vs. 5.6%). For other clinical issues there were minor or no differences. Both GP groups reported high levels of work-related stress with negative effect on self-perceived health (61.6% vs 64.6%). GPs who felt that high job demands harmed their health tended to handle a slightly higher number of medical issues per consultation and more consultations with elements of conflict.Conclusions and implicationsInexperienced GPs in Norway handle a workload comparable to that of experienced GPs, but they perceive more conflictual consultations. These findings have relevance for training and guidance of future GP specialists. Irrespective of experience, the GPs report such high levels of negative work-related stress as to indicate an acute need for organisational changes that imply a reduced workload.

Respiratory tract infections in Norwegian primary care 2006–2015: a registry-based study

Objective Examine characteristics and time trends of respiratory tract infection (RTI) consultations in Norwegian primary care and compare consultations in daytime general practice and out-of-hours (OOH) services. Design Registry-based study using reimbursement claims data. Setting All in-person primary care consultations during 2006–2015. Patients All patients visiting primary care during the study period. Main outcome measures The main outcome variable was RTI consultations. Differences regarding service type (general practice or OOH services) and changes over time were investigated. We report associations with patient age and sex, season, point-of-care C-reactive protein (CRP) test use, and sickness certificate issuing. Results RTI consultations (n = 16 304 777) represented 11.6% of all consultations (N = 140 199 637) in primary care over the ten-year period. The annual number of RTI consultations per 1000 inhabitants decreased from 335 to 314, while the number of consultations for any reason increased. Of RTI consultations, 83.2% occurred in general practice. OOH services had a higher proportion of RTI consultations (21.4%) compared with general practice (10.6%). Young children (0–4 years) represented 18.9% of all patients in RTI consultations. CRP testing was used in 56.2% of RTI consultations, and use increased over time. Sickness certificates were issued in 31.9% of RTI consultations with patients of working age (20–67 years). Conclusion Most RTI consultations occurred in general practice, although the proportion was higher in OOH services. Laboratory testing and/or issuing of sickness certificates were part of most consultations. This could be an important reason for seeking health care. Key Points Patients with a respiratory tract infection (RTI) are mostly managed in primary care, where they represent much of the workload. Most consultations for RTIs took place in daytime general practice, but out-of-hours services had a higher proportion of RTI consultations. RTIs were the dominating reason for encounter among young children both in out-of-hours services and daytime general practice. CRP tests were used in over half of RTI consultations, and their use expanded over time.

Patient experiences with depression care in general practice: a qualitative questionnaire study

Objective To investigate patient experiences and preferences regarding depression care in general practice. Design and setting A qualitative study based on free-text responses in a web-based survey in 2017. Participants were recruited by open invitation on the web page of a Norwegian patient organization for mental health. The survey consisted of four open-ended questions concerning depression care provided by general practitioners (GPs), including positive and negative experiences, and suggestions for improvement. The responses were analysed by Template Analysis. Subjects 250 persons completed the web-based survey, 86% were women. Results The analysis revealed five themes: The informants appreciated help from their GP; they wanted to be met by the GP with a listening, accepting, understanding and respectful attitude; they wanted to be involved in decisions regarding their treatment, including antidepressants which they thought should not be prescribed without follow-up; when referred to secondary mental care they found it wrong to have to find and contact a caregiver themselves; and they thought sickness certification should be individualised to be helpful. Conclusions Patients in Norway appreciate the depression care they receive from their GP. It is important for patients to be involved in decision-making regarding their treatment. KEY POINTS Depression is common, and GPs are often patients’ first point of contact when they seek help. • Patients who feel depressed appreciate help from their GP. • Patients prefer an empathetic GP who listens attentively and acknowledges their problems. • Individualised follow-up is essential when prescribing antidepressants, making a referral, or issuing a sickness absence certificate.

Primary care first contact practitioner’s (FCP) challenges and learning and development needs in providing fitness for work and sickness absence certification: consensus development

BackgroundAs yet, the benefit of the Fit Note has not been convincingly demonstrated, although a limited body of research suggests that provision of fitness for work advice and sickness absence certification may be improved with training and case-specific direction. The role of certifying sickness absence in the UK has traditionally been conducted by General Practitioners, but this role has now been extended to First Contact Practitioner (FCP) Physiotherapists in primary care. Therefore, FCPs may offer an ideal solution to the current challenges faced within primary care for those with a musculoskeletal (MSK) condition at risk of sickness absence from their work environment. ObjectivesThe main aim of this study was to identify the challenges and key learning and development needs of FCPs in response to providing Occupational Health (OH) information in the form of fitness for work advice and sickness certification for patients with MSK conditions within primary care. DesignConsensus was generated using an online modified version of the Nominal Group Technique (NGT) method. A priori consensus threshold of 60% was used in the voting stage. ParticipantsNGT participants included clinicians with experience in managing MSK conditions in primary care within the FCP model of care. All participants generated, voted, and ranked the items using an online platform. ConclusionsThis research adds new evidence regarding the challenges and learning and development needs identified by a group of FCPs working within primary care in consideration of sickness absence certification and fitness for work advice. The items highlighted provide evidence to complement Health Education England’s FCP A Roadmap to Practice educational pathway and informs on professional development needs in this area.

Interventions regarding physicians’ sickness certification practice – a systematic literature review with meta-analyses

Objective A variety of interventions aiming to influence physicians’ sickness certification practice have been conducted, most are, however, not evaluated scientifically. The aim of this systematic literature review was to obtain updated knowledge about interventions regarding physicians’ sickness certification practice and to summarize their possible effects, in terms of sickness absence (SA) or return to work (RTW) among patients. Methods We searched PubMed and Web of Science up through 15 June 2020 and selected peer-reviewed studies that reported effects of controlled interventions that aimed to improve physicians’ sickness certification practice and used SA or RTW among patients as outcome measures. Meta-analyses were conducted using random-effect models. Results Of the 1399 identified publications, 12 studies covering 9 interventions were assessed as relevant and included in the review. Most (70%) were from the Netherlands, two had a controlled, and seven a randomized controlled study design. All interventions included some type of training of physicians, and two interventions also included IT-support. Regarding the outcomes of SA/RTW, 30 different effect measures were used. In the meta-analyses, no statistically significant effect in favor of the interventions was observed for having any RTW (i.e. first, partial, or full) nor full RTW. Conclusions The individual studies showed that physicians’ sickness certification practice might be influenced by interventions in both the intended and non-intended direction, however, no statistically significant effect was indicated by the meta-analysis. The included studies varied considerably concerning intervention content and effect measures. KEY POINTS The knowledge is very limited regarding the content of interventions directed to physician’s sickness certification practice The identified interventions included some type of training of physicians, and some of them also included IT-support for physicians There was a great heterogeneity among the interventions concerning effect measures used regarding return to work among patients The individual studies showed that physicians’ sickness certification practice might be influenced by interventions in both intended and non-intended directions, however, the overall meta-analysis did not indicate an effect.

Intervention targeted at physicians’ treatment of musculoskeletal disorders and sickness certification: an interrupted time series analysis

ObjectiveAn intervention was carried out at the occupational healthcare services (OHS) of the City of Helsinki beginning in 2016. We investigated the association between the intervention and employee sick leaves...

Physician’s use of sickness certification guidelines: a nationwide survey of 13 750 physicians in different types of clinics in Sweden

ObjectivesTo explore physicians’ experiences of using the national sickness certification guidelines introduced in 2007 and the types of information they used, in general and in different types of clinics.DesignCross-sectional survey.SettingMost...

Factors associated with general practitioners' contacts with sick-listed patients' employers: A Swedish nationwide questionnaire study.

Background: General practitioners' (GP) contacts with sick-listed patients' employers have been shown to be of importance for return to work. This study aimed to explore GPs' contacts with sick-listed patients' employers and factors associated with such contacts. Methods: In this cross-sectional study, 4228 GPs responded to a nationwide questionnaire about sickness certification (SC) practices. Outcomes of interest were participation in stakeholder meetings, having other contacts with employers, and satisfaction with employer contacts. Logistic regression models were used to investigate associations with factors related to the GP and the GP's workplace. Results: Among GPs, 34.8% participated in stakeholder meetings and 15.1% had other employer contacts; 39.4% had any or both of these contacts. Of GPs who had contacts with patients' employers, 65.8% were satisfied with the contacts. GPs regularly collaborating with rehabilitation coordinators had the strongest adjusted odds ratio (OR) for participating in stakeholder meetings, OR 2.72 (95% confidence interval (CI) 2.24-3.31), and having other contacts with employers, OR 3.85 (95% CI 2.85-5.21). Other factors positively associated with employer contacts were being a specialist, collaborating with other health professionals, finding employer contacts valuable, and having a joint SC routine/policy at the clinic. GPs who did not find SC problematic, had managerial support, or had enough resources for SC tasks were more likely to be satisfied with their employer contacts. Conclusions: Both physician characteristics and organizational factors had importance for GPs' contacts with sick-listed patients' employers. The findings imply that GPs' collaboration with patients' employers may be improved by interventions targeting both individual and organizational factors.

The Doctor as Parent, Partner, Provider\u2026 or Comrade? Distribution of Power in Past and Present Models of the Doctor\u2013Patient Relationship

The commonly occurring metaphors and models of the doctor–patient relationship can be divided into three clusters, depending on what distribution of power they represent: in the paternalist cluster, power resides with the physician; in the consumer model, power resides with the patient; in the partnership model, power is distributed equally between doctor and patient. Often, this tripartite division is accepted as an exhaustive typology of doctor–patient relationships. The main objective of this paper is to challenge this idea by introducing a fourth possibility and distribution of power, namely, the distribution in which power resides with neither doctor nor patient. This equality in powerlessness—the hallmark of “the age of bureaucratic parsimony”—is the point of departure for a qualitatively new doctor–patient relationship, which is best described in terms of solidarity between comrades. This paper specifies the characteristics of this specific type of solidarity and illustrates it with a case study of how Swedish doctors and patients interrelate in the sickness certification practice.

Oncologists' experiences of and prerequisites for sickness certification tasks: A nationwide questionnaire study.

To investigate oncologists' experiences of organisational prerequisites for SC tasks, and if lack of resources was related to experiencing SC as problematic. Questionnaire data from 342 oncologists in Sweden were used for descriptive statistics and to calculate odds ratios (OR) with 95% confidence intervals (CI). The majority (92.2%) had SC consultations weekly; 17.8% of the oncologists experienced such consultations as problematic weekly. About a third appreciated the national guidelines for SC (34.5%) and had joint routines/policies regarding SC at their clinic (29.7%). Experiencing SC consultations as problematic was associated with stating not having enough resources for such work (OR 3.47; 95% CI 1.92-6.25). Lack of resources was associated with: experiencing lack of competence in insurance medicine (3.34; 1.92-5.82), conflicts with patients regarding SC (4.22; 1.96-9.07), finding it problematic to manage the two roles as medical expert and as the patient's treating physician (3.31; 2.04-5.34), or to assess work capacity (2.28; 1.46-3.56). Although oncologists often had SC tasks, most did not experience them as problematic weekly. However, lack of resources for SC tasks was associated with experiencing SC as problematic.

Rehabilitation of the working population after occupation injuries

Introduction. The urgency to maintain health and man’s working population’s performance capability is inextricably linked to occupation-related injuries. They remain one of the most relevant heads of losses for both the employee and the employer and the state in the form of insurance benefits, sickness certificates, disability benefits, rehabilitation programs, and compensation payments. High rate of posttraumatic complications, disability and demographic losses call for improving in the treatment delivery at all its stages. The purpose is to improve rehabilitation effectiveness in patients after job-related injuries in recognition of the international classification of functioning of post-traumatic disorders of the upper extremities. Material and methods. 3,201 patients with domestic and job-related injuries of the body’s locomotor apparatus underwent rehabilitation treatment within second and third rehabilitation stages under twenty-four-hour inpatient treatment and outpatient care. Upper extremities injuries were in 57% cases; lower extremities injuries - 38%. Combined injuries made up 5 %. Since 2020, there has been introduced the work of a multidisciplinary team (MDT), consisting of doctors of physical and rehabilitation medicine (PRM) as well as doctors of physical therapy, neurologists, internists, reflexologist, traumatologist, doctors in exercise therapy, trainers in exercise therapy, clinical psychologists, ergotherapists, and specialized doctors (cardiologist, dietitian, endocrinologist, osteoporosis specialist, etc.). Results. The clinical practice of using treatment methodology from the position of rehabilitation potential and diagnosis is shown. Possible ways for improving the effectiveness of recovering the population’s health after injuries are analyzed using international standards. The main steps, tasks, and medical and social rehabilitation opportunities are discussed using the international classification of functioning, disability, and health (ICF). Conclusion. Our experience with patients of a traumatic profile, including individuals after job-related injuries, shows the reasonableness of using ICF in rehabilitation as a unified international tool and should be further used.

Multimorbidity and fit note receipt in working-age adults with long-term health conditions.

Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population. Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017. We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95). Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.