Sickness Certification Research Articles

Stakeholder perspectives on the new sickness certificate in Victoria: results from a mixed-methods qualitative study.

OBJECTIVE; The aim ofthis study was to present the views of four stakeholder groups, namely general practitioners (GP), employers (EMP), injured workers (IW) and compensation agents (CA), about the content and usability of the draft of the new Victorian sickness certificate. A cross-sectional mixed-methods qualitative study was conducted in GP clinics and community settings in Melbourne, Australia. Interviews were conducted with GPs, EMPs and IWs and one focus group discussion was completed with CAs (n = 29). Data were collected between October and December 2013. Thematic analysis was performed. All stakeholders viewed the new draft certificate as an improvement on the old one. GPs saw the certificate as a form of communication, whereas EMPs and CAs saw it as a therapeutic device. GPs continued to certify based on incapacity and provided little information about what IWs could do on return to work. All groups said that assessments for mental health needed more clarity and specificity. GPs, EMPs and CAs also said that the new certificates must be electronically available and integrated into existing medical software to streamline uptake. To ensure appropriate use of the new certificate, stakeholders must share a common understanding about its purpose and the certificate must be incorporated into existing medical software. Content on mental health assessment, an area of continued difficulty, needs additional refinement. The new certificate replaced the old certificate in March 2015; after it has been established in clinical practice, an impact evaluation should be completed to determine whether GPs are certifying capacity and earlier return to work.

Patients' attitudes to sickness certification in general practice.

In 2010, the sick note was replaced with the fit note, designed to enable return to work. Despite considerable research relating to general practitioners' (GPs') attitudes and practice towards the fit note, little is known regarding the patients' perspective. We sought to identify patients' attitudes to and feelings about the process of sickness certification. Patients who received fit notes were invited to participate in tape-recorded telephone interviews, which were conducted with a semi-structured approach. Participants described their reason for sickness absence and whether it had been related to work. They were then asked to provide a narrative regarding their experience of the fitness for work process and their feelings about their GP and employer's reaction to sickness absence. Nine patients were interviewed. Four main themes emerged from analysis of the interviews: 'significant stigma', 'a GP who knows me', 'value of work' and 'emotional barriers'. Patients expressed preference for being seen by a familiar GP with a greater perceived understanding of the patient's attitude to sickness and work. The four emergent themes of stigma, the value of work, a doctor who knows you and emotion suggest that further research should focus on the problems of stigma associated with sickness certification and patients' emotional response to asking for certification.

Sick-listing adherence: a register study of 1.4 million episodes of sickness benefit 2010-2013 in Sweden.

BackgroundThis register study aims to increase the knowledge on how common it is that sickness benefit recipients are sick-listed for as long as their physician prescribes in their medical sickness certificate, i.e. sick-listing adherence, or wholly/partly bring return-to-work (RTW) forward, i.e. early RTW.MethodsThe unit for analysis was an episode of 100% sickness benefit, commenced between 1 January 2010 and 31 December 2013. Completed episodes of sickness benefit and full or partial early RTW was analysed by comparing the prescribed length of sick leave in medical sickness certificates and benefit days disbursed by the sickness insurance system. Probability for a full and partial early RTW was estimated with hazard ratio (HR) using the Cox proportional hazard model.ResultsIn total, about 1.4 million episodes of sickness benefit (60% women) were included in the study. The overall sick-listing adherence was 84% for women and 82% for men during the first year of sick leave. Adherence varied between 82 and 87% among women and between 79 and 86% among men with regard to ICD-10 diagnosis chapter. The probability of an early RTW varied between diagnosis chapters, where mental disorders was associated with a lower probability of a full early RTW among women and men (HR 0.52 and HR 0.47) as well as a partial early RTW (HR 0.51 and HR 0.46). Younger age (16–29 years), high educational level and high income was associated with a higher probability of an early RTW, while older age (≥50 years), not native-born, low educational level, unemployment and parental leave were associated with a lower probability.ConclusionThe study demonstrates that sick-listing adherence is relatively high. Probability of an early RTW differs with regard to diagnosis chapter, demographic, socioeconomic and labour market characteristics of the sickness benefit recipients. Interventions intended to improve the sick-listing process, and to affect the length and degree of sick leave in certain target groups, should include measures targeted at physicians’ sick-listing practices. Policies and economic incentives aimed at promoting RTW need to focus on individuals’ residual capacity for work.

Trends of sickness certifications in primary health care in muscat, sultanate of oman.

Sickness certification (SC) is common practice in primary health care with proven implications on the health system. To assess the rate of sickness certifications in the Bowsher province and describe related demographic, occupational and medical factors. Our retrospective, cross-sectional study retrieved data for all consultations, with patients aged six to 65 years old, which ended with SC. The data from four primary health care centers in the Bowsher provice were collected during 2011 using the electronic medical record system. Collected data included patient demographics, occupation, date issued, duration of sickness certification, recorded vital signs, and clinical diagnosis. Suitable rates were calculated as percentages and important differences were compared using the chi-square test. The total number of consultation visits for the targeted population was 189,275. Of these 26,096 consultations resulted in SC to a total of 15,758 patients. The overall rate of SC was 13.8 per 100 consultation-years (confidence interval (CI): 13.6-14). SC rates in males were significantly higher than females (17 and 11 per 100 consultations/year, respectively). Patients aged 19-29 years old had the highest rate of SC (18.6/100 consultations/year). School students aged six to 18 years made up 28% of patients, and 24% and 22% of patients were working in the private and public sectors, respectively. No vital signs record was found for 30% of SC visits. The highest rate of SC was in October (17%) and the lowest was in August (9%). Acute respiratory infections were the most frequent diagnoses (31%) resulting in certifications. The rate of SC issued for Omanis and non-Omanis was 14 and 9 per 100 consultations per year, respectively. Sickness certification is a burden on primary health care in the studied health centers with approximately one in seven consultations ending with SC issued. More investigations are needed to identify determinates of high sickness absence. Robust guidelines are important to regulate the number of sickness certificates issued.

Has the fit note reduced general practice sickness certification rates?

In 2010, the fit note replaced the sick note to help focus on what people are capable of doing, rather than signing patients 'off sick'. To compare proportions of work-related ill-health issued with sickness certification pre- and post-fit note introduction and assess sickness absence trends. General practitioners (GPs) report data on work-related ill-health and sickness absence via The Health and Occupation Research network in General Practice. The proportion of cases issued with sickness certification 4 years before and 3 years after the fit note introduction were compared. Changes in certification incidence rate ratios were measured over time. Participating GPs reported 5517 cases of work-related ill-health. Pre-fit note introduction 50% of cases were certified sick. There was no change in the proportion of cases certified sick in the first year post-fit note, despite 13% of cases classified as 'maybe fit'. However, in the second year, the proportion of cases certified sick had reduced significantly (41%) and a larger proportion (19%) was advised on workplace adjustments. In the third year post-introduction, there was a slight rise in the proportion of cases certified sick; therefore, although there was a fall of 2% per annum in certification rates, this was not significant. In the first year post-fit note introduction, modifications to work were recommended for people who would previously have been declared fit. Trends analyses showed a slight decrease in the certification rate, possibly indicating GPs will become more practised in advising on workplace adjustments.

Factors associated with the length of fit note-certified sickness episodes in the UK

ObjectivesTo identify diagnostic, patient/employee, general practitioner (GP) and practice factors associated with length of certified sickness episodes.MethodsTwelve-month collection of fit note data at 68 general practices in eight regions of...

Should General Practitioners Issue a Sick Certificate to Employees Who Consult for Low Back Pain in Primary Care?

Purpose Back pain is a common problem and has significant societal impact. Sickness certification is commonly issued to patients consulting their general practitioner with low back pain. The aim of this study was to investigate the association of certification for low back pain with clinical outcomes and cost consequences. Methods A prospective cohort study using linked questionnaire and medical record data from 806 low back pain patients in 8 UK general practices: comparison of 116 (14.4 %) who received a sickness certificate versus 690 who did not receive certification. The primary clinical measure was the Roland and Morris Disability Questionnaire (RMDQ). Data on back pain consultation and work absenteeism were used to calculate healthcare and societal costs. Results Participants issued a sickness certificate had higher back-related disability at baseline consultation and 6-month follow-up [mean difference 3.1 (95 % CI 1.8, 4.4) on the RMDQ], indicating worse health status. After fully adjusting for baseline differences, most changes in clinical outcomes at 6 months were not significantly different between study groups. Productivity losses were significantly higher for the certification group, with most absence occurring after the expected end of certification; mean difference in costs due to absenteeism over 6 months was £1,956 (95 % CI £941, £3040). Conclusions There was no clear evidence of a difference in clinical outcomes between individuals issued a sickness certificate and those not issued a certification for their back pain. With little overall contrast in clinical outcomes, policy makers and care providers may wish to draw on the likely difference in societal costs alongside issues in ethical and moral care in their consideration of patient care for low back pain.

The influence of prior training on GPs' attitudes to sickness absence certification post-fit note.

Aim To investigate the attitudes to health and work of general practitioners (GPs) with training in occupational medicine (OM) compared with non-OM trained GPs, since the introduction of the fit note. Changes to the UK sickness certification system since 2010 and the introduction of the fit note required GPs to change their focus to what patients can do, rather than what they cannot do in relation to work. In an effort to reduce the UK sickness absence burden, GPs completion of the fit note should help to keep people in work, or assist patients to return to work as quickly as possible after a period of absence. Questionnaire data were collected via the 7th National General Practitioner Worklife Survey. Findings Results indicate that responses from GPs who had undertaken training in OM, and GPs having received some form of work and health training in the 12-month period before the study were associated with significantly more positive attitudes to patients' returning to work and to the fit note. This study reveals evidence of a difference between trained and non-trained GPs in their attitude to the fit note, and to work and health generally. Further work investigating the effect of specific training in OM on the management and recognition of ill-health by GPs is recommended.

GPs’ negotiation strategies regarding sick leave for subjective health complaints

Objectives. To explore general practitioners’ (GPs’) specific negotiation strategies regarding sick-leave issues with patients suffering from subjective health complaints. Design. Focus-group study. Setting. Nine focus-group interviews in three cities in different regions of Norway. Participants. 48 GPs (31 men, 17 women; age 32–65), participating in a course dealing with diagnostic practice and assessment of sickness certificates related to patients with subjective health complaints. Results. The GPs identified some specific strategies that they claimed to apply when dealing with the question of sick leave for patients with subjective health complaints. The first step would be to build an alliance with the patient by complying with the wish for sick leave, and at the same time searching for information to acquire the patient's perspective. This position would become the basis for the main goal: motivating the patient for a rapid return to work by pointing out the positive effects of staying at work, making legal and moral arguments, and warning against long-term sick leave. Additional solutions might also be applied, such as involving other stakeholders in this process to provide alternatives to sick leave. Conclusions and implications. GPs seem to have a conscious approach to negotiations of sickness certification, as they report applying specific strategies to limit the duration of sick leave due to subjective health complaints. This give-and-take way of handling sick-leave negotiations has been suggested by others to enhance return to work, and should be further encouraged. However, specific effectiveness of this strategy is yet to be proven, and further investigation into the actual dealings between doctor and patients in these complex encounters is needed.

Arbeitsunfähigkeitsregelungen als Faktor für Inanspruchnahme ärztlicher Versorgung in Deutschland

In Germany, utilization of ambulatory health care is high compared to other countries. Classical models of health care utilization cannot sufficiently explain these differences. The aim of this study was to explore relevant factors which can explain the higher health care utilization in Germany. In this article, we focus on regulations regarding sickness certification as a potential factor. An explorative qualitative study design. We conducted episodic interviews with 20 patients in Germany and 20 patients in Norway and participant observation in four primary care practices each. Additionally, we conducted a context analysis of relevant health care system related factors which emerged during the study. Qualitative data analysis was done by thematic coding in the framework of grounded theory. The need for a sickness certificate was an important reason for encounter in Germany, especially regarding minor illnesses. Sickness certification is a societal topic. GPs play a double role regarding sickness certification, both as the patients' advocate and as an expert witness for social security services. In Norway, longer periods of self-administered sickness certification and more differentiated possibilities of sickness certification have been introduced successfully. Our results point to regulations regarding sickness certification as a relevant factor for higher health care utilization in Germany. In pilot studies, the effect of extended self-certification of sickness and part-time sickness certification should be further assessed.

Collaboration in work ability assessment for sick-listed persons in primary healthcare.

General practitioners (GPs) have expressed difficulties in issuing sickness certificates and problems may arise if this work is not performed in an adequate manner. There is scant knowledge about how collaboration with other professions could be organized to enhance this work. Evaluate the feasibility of occupational therapists (OTs) performing supplementary assessments for persons on sick leave. Four healthcare centres (HCs) tested a working approach intervention where sick-listed patients were offered a complementary occupational therapy assessment. The OT assessments were intended to provide useful information for GP issued extended sickness certificates. Data on sick leave, sickness certificates and patient questionnaires were collected at different HCs. Interviews were conducted with GPs and OTs and the Consolidated Framework for Implementation Research was used to analyse the intervention's implementation. No major differences in the sickness certificate quality was found. Available data on sick leave increased for all HCs during the project. Not all GPs used the OT assessments, which indicates that the implementation of the intervention was insufficient. Testing a new working approach in primary healthcare requires an implementation strategy. To improve sickness certification quality, this work needs to be prioritized as an important healthcare task.

Patient empowerment in the process of sickness certificates.

A national patient portal for secure communication between the patients/citizens and primary care (Mina vårdkontakter) is available in Sweden. This system was used in a pilot project in the Stockholm County where patients were invited to prepare the visit to their physician for the discussion on the need for prolonged sickness leave by filling out a web based questionnaire on their current health status and working conditions. The opinions of the patients and their primary care physicians about the system were analyzed with positive feedback.

Practices used for recommending sickness certification by general practitioners: A conversation analytic study of UK primary care consultations

Existing research indicates that many patients and doctors find the process of negotiating sickness certification for time off work to be a difficult one. This study examined how patients and general practitioners (GPs) managed these negotiations in a sample of UK primary care consultations. The study made use of an existing dataset of audio-recorded consultations between 13 GPs and 506 unselected adult patients in five general practices in London. Forty-nine consultations included discussions for both initial and repeat sickness certification across a wide range of conditions. Here we report our findings on doctor practices for recommending, as opposed to patient practices for advocating for, sickness certification (n = 26 cases). All cases were transcribed in detail and analysed using conversation analytic methods. Four main communication practices were observed: (1) declarative statements of need for sickness certification; (2) ‘do you need’ offers for sickness certification; (3) ‘do you want’ offers for sickness certification; and (4) conditional ‘If X, Y’ offers for sickness certification. These different communication practices indexed doctor agency, doctor endorsement and patient entitlement to varying degrees. In the main, recommendations to patients presenting with biomedical problems or a repeat occurrence of a psychosocial problem displayed stronger doctor endorsement and patient entitlement. Contrastingly, recommendations to patients presenting with new psychosocial and biopsychosocial problems, displayed weaker endorsement and patient entitlement. This study offers new evidence to support the Parsonian argument that becoming sick involves entering a social role with special rights and obligations. Through documenting doctors' orientations to their gatekeeping role as well as patients' orientations to differential rights vis à vis legitimacy, we demonstrate the contrasting stances of doctors in situ when giving sick notes for biomedical problems as opposed to difficulties of a more psychosocial nature.

Social insurance administrative officers’ perceptions of their assignment and problematic issues in their work with heart failure clients in the sick-leave and rehabilitation process

This article explores social insurance administrative officers’ (AOs’) perceptions of the sick-leave process for heart failure clients. The work situation and the sick-leave process for people with heart failure tend to be complex and problematic. The problems are often caused by a lack of understanding from professionals, such as social insurance AOs. The study draws on two focus group interviews with social insurance AOs from two different social insurance agencies. The interviews were guided by an open approach, and analysis was performed on the interviews’ manifest content through a qualitative content analysis. The findings demonstrate that the AOs were concerned about the clients’ ability to return to work, but they were hindered in fulfilling their duties through insufficient collaboration with physicians and unclear sickness certificates. There seems to be a gap between the AOs’ assignment and their ability to make well-founded decisions about their clients’ ability to work. This can have consequences for the individual who lives with heart failure. In the sociopolitical agenda of Sweden, this can have consequences for the development of collaboration between AOs and the medical experts who provide the foundations for decisions about work ability of the client with heart failure.

Functional outcome and satisfaction with a "self-care" protocol for the management of mallet finger injuries: a case-series.

BackgroundMallet finger injuries are usually successfully treated non-operatively with a splint. Most patients are reviewed at least twice in a clinic after the initial presentation in A&E. A new protocol promoting “self-care” was introduced at our institution. Patients were provided with structured verbal and written information, and given access to a telephone helpline.MethodsA prospective electronic patient record was used to identify all patients who presented to the emergency department with a mallet finger with a minimum six month follow-up. A satisfaction and patient reported outcome measure was administered via a postal questionnaire. The response rate was 36/47 (77%).ResultsThe median QuickDASH score was 2.3 (IQR 0 to 4.6). All patients were satisfied with the treatment plan provided. Nine used the helpline and all were satisfied with information given. Although 13 patients reported some extensor lag, or bump, they had no functional limitation. Seven patients were reviewed by the general practitioner or other clinicians during their treatment period for issues such a skin care, splint size changes or sickness certification. Five were subsequently reviewed at the end of their treatment period in a clinic at their request, or their general practitioner, but did not require further surgical intervention.ConclusionsSelf-care for mallet finger injuries, with adequate patient information and telephone back-up, leads to acceptable functional results and satisfaction.Level of evidence: III

How common is change of primary diagnosis during an episode of sickness benefit? A register study of medical sickness certificates issued 2010-2012 in Sweden.

The aims of this study were to investigate how common it is to change primary diagnosis between different diagnostic chapters during a sick-leave spell, and to explore patterns of diagnostic changes. The unit for analysis was episode of sickness benefit, that is, sick leave >14 days, which commenced between 2010 and 2012 in Sweden. For each case, the primary diagnosis was retrieved from the first and last/latest medical sickness certificate, respectively. The number of days of sickness benefit was linked to the cases. Any change of primary diagnosis was analysed by diagnostic chapter according to the ICD-10, and this was done separately for women and men. In total, 803,041 cases of sickness benefit (63% women) were included in the study. During a sick-leave spell, 7.1% of female cases and 6.6% of male cases changed their primary diagnosis to a diagnosis from another diagnostic chapter. The change of primary diagnosis increased with the number of days with sickness benefit. For female cases, this increase was from 2.0% for cases that lasted 15-30 days to 20.2% for cases that lasted >365 days. For male cases, the corresponding increase was from 1.8% to 21.2%. A change of primary diagnosis was least common among those initially sick-listed for mental disorders and musculoskeletal disorders. The patterns of diagnostic changes were rather similar for women and men. A change of diagnosis during a sick-leave spell needs to be taken into consideration by the sickness insurance system and in the actions taken by its administration. Registry-based studies of sickness insurance need to consider diagnostic changes in both the study design and the interpretation of results.

Impact of a nationwide government program in Sweden on how healthcare managers, in their organisations, manage the work with sickness certification of patients

Impact of a nationwide government program in Sweden on how healthcare managers, in their organisations, manage the work with sickness certification of patients

A study of general practitioners’ sickness certification rates and their role in sickness absence

A study of general practitioners’ sickness certification rates and their role in sickness absence

Associations between number of sick-leave days and future all-cause and cause-specific mortality: a population-based cohort study.

BackgroundAs the number of studies on the future situation of sickness absentees still is very limited, we aimed to investigate the association between number of sick-leave days and future all-cause and cause-specific mortality among women and men.MethodsA cohort of 2 275 987 women and 2 393 248 men, aged 20–64 years in 1995 was followed 1996–2006 with regard to mortality. Data were obtained from linked authority-administered registers. The relative risks (RR) and 95% confidence intervals (CI) of mortality with and without a 2-year wash-out period were estimated by multivariate Poisson regression analyses. All analyses were stratified by sex, adjusting for socio demographics and inpatient care.ResultsA gradually higher all-cause mortality risk occurred with increasing number of sick-leave days in 1995, among both women (RR 1.11; CI 1.07-1.15 for those with 1–15 sick-leave days to RR 2.45; CI 2.36-2.53 among those with 166–365 days) and men (RR 1.20; CI 1.17-1.24 to RR 1.91; CI 1.85-1.97). Multivariate risk estimates were comparable for the different causes of death (circulatory disease, cancer, and suicide). The two-year washout period had only a minor effect on the risk estimates.ConclusionEven a low number of sick-leave days was associated with a higher risk for premature death in the following 11 years, also when adjusting for morbidity. This was the case for both women and men and also for cause-specific mortality. More knowledge is warranted on the mechanisms leading to higher mortality risks among sickness absentees, as sickness certification is a common measure in health care, and most sick leave is due to diagnoses you do not die from.

Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study.

BackgroundMusculoskeletal complaints have a significant impact on work in terms of reduced productivity, sickness absence and long term incapacity for work. This study sought to explore GPs’ and physiotherapists’ perceptions of sickness certification in patients with musculoskeletal problems.MethodsEleven (11) GPs were sampled from an existing general practice survey, and six (6) physiotherapists were selected randomly using ‘snowball’ sampling techniques, through established contacts in local physiotherapy departments. Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes. The interviews were audio recorded and transcribed verbatim, following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology, where themes were identified and contrasted between and within both groups of respondents.ResultsThree themes were identified from the analysis: 1) Approaches to evaluating patients’ work problems 2) Perceived ability to manage ‘work and pain’, and 3) Policies and penalties in the work-place. First, physiotherapists routinely asked patients about their job and work difficulties using a structured (protocol-driven) approach, whilst GPs rarely used such structured measures and were less likely to enquire about patients’ work situation. Second, return to work assessments revealed a tension between GPs’ gatekeeper and patient advocacy roles, often resolved in favour of patients’ concerns and needs. Some physiotherapists perceived that GPs’ decisions could be influenced by patients’ demand for a sick certificate and their close relationship with patients made them vulnerable to manipulation. Third, the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption, and over which GPs and physiotherapists could exercise only limited control.ConclusionWe conclude that healthcare professionals need to take account of patients’ work difficulties, their own perceived ability to offer effective guidance, and consider the ‘receptivity’ of employment contexts to patients’ work problems, in order to ensure a smooth transition back to work.