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The Sick Leave Process: Sick Leave Guidelines, Sickness Certificates, and Experiences of Professionals
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Decisions on entitlement to sickness benefits and return to work interventions have substantial impact on individuals’ lives and on society. In most Western European countries, such decisions are based on sickness certificates, which should provide information on how a disease or injury reduces the individual’s work ability. These are challenging and complex assessments. In 2008, guidelines for the management of sick leave were implemented in Sweden, emphasizing early assessments of work ability and return to work, and increasing the quality demands of sickness certificates by underscoring descriptions of activity limitations related to work. The overall aim of this thesis was to gain a deeper knowledge of the sick leave process with special emphasis on the content of sickness certificates and primary health care (PHC) professionals’ experiences with the process. Specific aims were to compare the quality of sickness certificates regarding descriptions of functioning by the use of WHO’s International Classification of Functioning, disability, and health (ICF), as well as the prescribed interventions before versus after implementation of the Swedish sick leave guidelines.

The thesis comprises three studies. A cross-sectional design was used in studies I and II, which included 475 and 501 new sickness certificates consecutively collected in Östergötland County, Sweden, in 2007 and 2009, respectively. Text on functioning was analysed with a deductive content analysis using the ICF. Study III was an exploratory study using data from four semi-structured focus group discussions with a purposeful sample of PHC professionals (n=18) in Östergötland County. An inductive content analysis was used in this study.

The thesis comprises three studies. A cross-sectional design was used in studies I and II, which included 475 and 501 new sickness certificates consecutively collected in Östergötland County, Sweden, in 2007 and 2009, respectively. Text on functioning was analysed with a deductive content analysis using the ICF. Study III was an exploratory study using data from four semi-structured focus group discussions with a purposeful sample of PHC professionals (n=18) in Östergötland County. An inductive content analysis was used in this study.

An overall conclusion drawn from this thesis is that patient functioning and needs might not be adequately communicated in the sick leave process. Despite the implementation of sick leave guidelines, this information is limited in sickness certificates and the collaboration is poor among the involved stakeholders, i.e., health care, the social insurance office, the employer and the OHS. The basis for decisions on entitlement to sickness benefits could be improved by including a description of the patients’ activity limitations or participation restrictions related to work demands. One way to enhance the decision basis might be to use the available team competencies at the PHC.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 75 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1354
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-89838ISBN: 978-91-7519-689-3 (print)OAI: oai:DiVA.org:liu-89838DiVA: diva2:609920
Public defence
2013-04-05, Aulan, Hälsans Hus ingång 16, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2013-03-08 Created: 2013-03-08 Last updated: 2013-03-08Bibliographically approved
List of papers
1. Description of functioning in sickness certificates
Open this publication in new window or tab >>Description of functioning in sickness certificates
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 5, 508-516 p.Article in journal (Refereed) Published
Abstract [en]

Aims: Sickness certificates are to provide information on a disease and its consequences on the patients functioning. This information has implications for the patients rights to sickness benefits and return-to-work measures. The objective of this study was to investigate the description of functioning in sickness certificates according to WHOs International Classification of Functioning, Disability, and Health (ICF), and to describe the influence of patients age, gender, diagnostic group, and affiliation of certifying physician. Method: A content analysis of written statements regarding how the disease limits the patients functioning with ICF as a framework was performed in 475 sickness certificates, consecutively collected in Ostergotland County, Sweden. Results: Musculoskeletal diseases (MSD) were the largest diagnostic group, followed by mental disorders (MD). Certificates were mainly issued from physicians at hospitals and in primary health care (PHC). ICF was applicable for classifying statements regarding functioning in 311 certificates (65%). The distribution of components was 58% body functions, 26% activity, and 7% participation. The descriptions were primarily restricted to the use of at least one component; namely, body functions. Subgroup analysis showed that descriptions of activity and participation were more common in certificates for MD and MSD, or those issued by PHC physicians. A multiple regression analysis with the activity component as dependent variable confirmed the results by showing that activity was related to both diagnosis and affiliation. Conclusions: In a consecutive sample of sickness certificates, it was shown that information on functioning is scarce. When functioning was described, it was mainly body oriented.

Place, publisher, year, edition, pages
Sage, 2011
Keyword
International Classification of Functioning; Disability; and Health; mental disorders; musculoskeletal diseases; physicians assessment of work capacity; sick leave
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-69815 (URN)10.1177/1403494811399954 (DOI)000292539900009 ()
Note
The final, definitive version of this paper has been published in: Scandinavian Journal of Public Health, (39), 5, 508-516, 2011. Emma Nilsing, Elsy Söderberg, Helena Normelli and Birgitta Öberg, Description of functioning in sickness certificates http://dx.doi.org/10.1177/1403494811399954 by SAGE Publications Ltd, All rights reserved. http://www.uk.sagepub.com/ Available from: 2011-08-10 Created: 2011-08-08 Last updated: 2017-12-08
2. Sickness certificates: what information do they provide about rehabilitation?
Open this publication in new window or tab >>Sickness certificates: what information do they provide about rehabilitation?
2014 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 36, no 15, 1299-1304 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: To investigate whether patients are prescribed rehabilitation early in a new sick leave period, and whether this prescription is associated with age, sex, diagnosis, description of functioning, and affiliation of certifying physician.

Methods: A cross-sectional study using data from sickness certificates issued during a total sick leave period, collected consecutively during 2 weeks in 2007 in Östergötland County, Sweden. Rehabilitation prescribed in the first certificate or within 28 days after the start of sick leave was defined as early rehabilitation.

Results: Musculoskeletal diseases (MSD) were the largest diagnostic group, followed by mental disorders (MD). The mean certified duration of sick leave was 94 days (SD 139), longest for MD patients. Early rehabilitation was prescribed in 27% of all certificates and in 45% of certificates for MSD and MD diagnoses. Logistic regression analysis indicated that prescription of early rehabilitation was associated with certificates issued for MSD and MD, youngest patients, and certificates issued by primary health care physicians. The final model explained 29% of variation in the prescription of early rehabilitation.

Conclusion: There is a modest prescription of early rehabilitation in sickness certificates, based on younger age and MSD or MD diagnosis. This indicates that patients’ rehabilitation needs may not have been identified.

Keyword
Sick leave, musculoskeletal diseases, mental disorders, physicians, physiotherapy, vocational rehabilitation, Sweden
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-89837 (URN)10.3109/09638288.2013.836252 (DOI)000340450300010 ()24063292 (PubMedID)
Available from: 2013-03-08 Created: 2013-03-08 Last updated: 2017-12-06
3. Sickness certificates in Sweden: did the new guidelines improve their quality?
Open this publication in new window or tab >>Sickness certificates in Sweden: did the new guidelines improve their quality?
2012 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 12, no 907Article in journal (Refereed) Published
Abstract [en]

Background: Long-term sickness absence is high in many Western countries. In Sweden and many other countries, decisions on entitlement to sickness benefits and return to work measures are based on information provided by physicians in sickness certificates. The quality demands, as stressed by the Swedish sick leave guidelines from 2008, included accurate sickness certificates with assessment of functioning clearly documented. This study aims to compare quality of sickness certificates between 2007 and 2009 in Ostergotland County, Sweden. Quality is defined in terms of descriptions of functioning with the use of activity and participation according to WHOs International Classification of Functioning, Disability and Health (ICF), and in prescriptions of early rehabilitation. less thanbrgreater than less thanbrgreater thanMethods: During two weeks in 2007 and four weeks in 2009, all certificates had been collected upon arrival to the social insurance office in Ostergotland County, Sweden. Four hundred seventy-five new certificates were included in 2007 and 501 in 2009. Prolongations of sick leave were included until the last date of sick listing. Free text on functioning was analysed deductively using the ICF framework, and placed into categories (body functions/structures, activity, participation, no description) for statistical analysis. less thanbrgreater than less thanbrgreater thanResults: The majority of the certificates were issued for musculoskeletal diseases or mental disorders. Text on functioning could be classified into the components of ICF in 65% and 78% of sickness certificates issued in 2007 and 2009, respectively. Descriptions according to body components such as "sensations of pain" or "emotional functions" were given in 58% of the certificates from 2007 and in 65% from 2009. The activity component, for example "walking" or "handling stress", was more frequent in certificates issued in 2009 compared with 2007 (33% versus 26%). Prescriptions of early rehabilitation increased from 27% in 2007 to 35% in 2009, primarily due to more counseling. less thanbrgreater than less thanbrgreater thanConclusions: An improvement of the quality between certificates collected in 2007 and 2009 was demonstrated in Ostergotland County, Sweden. The certificates from 2009 provided more information linkable to ICF and incorporated an increased use of activity limitations when describing patients functioning. Still, activity limitations and prescriptions of early rehabilitation were only present in one-third of the sickness certificates.

Place, publisher, year, edition, pages
BioMed Central, 2012
Keyword
Sickness certificates, International Classification of Functioning, Disability and Health (ICF), Rehabilitation, Sick leave, Physicians, Functioning, Work ability, Sweden
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-86657 (URN)10.1186/1471-2458-12-907 (DOI)000311617300001 ()
Note

Funding Agencies|National Social Insurance Administration||County Council in Ostergotland, Sweden|IHS 7/0728|

Available from: 2012-12-20 Created: 2012-12-20 Last updated: 2017-12-06
4. Primary Healthcare Professionals' Experiences of the Sick Leave Process: A Focus Group Study in Sweden
Open this publication in new window or tab >>Primary Healthcare Professionals' Experiences of the Sick Leave Process: A Focus Group Study in Sweden
2013 (English)In: Journal of occupational rehabilitation, ISSN 1053-0487, E-ISSN 1573-3688, Vol. 23, no 3, 450-461 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The aim of this study was to explore primary healthcare (PHC) professionals' experiences of the sick leave process. Methods This is an explorative study using data from four semi-structured focus group discussions with a purposeful sample of PHC professionals in A-stergotland County, Sweden. Content analysis with an inductive approach was used in the analysis. Results Four key themes emerged from the analysis; priority to the sick leave process, handling sickness certifications, collaboration within PHC and with other stakeholders, and work ability assessments. Patients' need for sick leave was handled from each professional group's perspective. Collaboration was considered important, but difficult to achieve and all the competencies available at the PHC centre were not used for work ability assessments. There was insufficient knowledge of patients' work demands and contact with an employer was rare, and the strained relationship with the social insurance officers affected the collaboration. Conclusions This study highlights the challenges physicians and other PHC professionals face when handling the need for sick leave, especially when encountering patients with symptom-based diagnoses, and the influence of non-medical factors. Hindrances to good practice were increased demands, collaboration, and role responsibility. The challenges in the sick leave process concerned both content and consequences related to poor collaboration within PHC and with representatives from various organizations, primarily employers and social insurance officers. Further research on how to develop a professional approach for handling the sick leave process is needed.

Place, publisher, year, edition, pages
SPRINGER/PLENUM PUBLISHERS, 2013
Keyword
Sick leave, Work ability, Rehabilitation, Return to work, Physicians, Healthcare professionals, Sickness certificates, Primary healthcare, Sweden
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-89836 (URN)10.1007/s10926-013-9418-0 (DOI)000322880900015 ()23345119 (PubMedID)
Available from: 2013-03-08 Created: 2013-03-08 Last updated: 2017-12-06Bibliographically approved

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