A systematic review of published studies showed that physicians experience sickness certification as problematic,1
and this was confirmed by later investigations,2–8
even to such an extent that it was considered a work environmental problem.9
Also, considering patients with the same complaints, there has been marked variation in whether sickness certificates have been issued and, if so, for how long; this applies especially to some of the vague diagnoses that are common in primary healthcare (PHC) and which underlie a large proportion of all sick-leave days.1 8 10
Clinical practice guidelines have been defined as ‘systematically developed statements to assist practitioners' and patients' decisions about appropriate healthcare for specific clinical circumstances’.11
Such recommendations play an important role in enabling knowledge on best practice and evidence-based medicine to be implemented in routine practice. Improvements in quality of care and reduction of variation in practice are common reasons for establishing guidelines.12
This is exemplified by the comprehensive and detailed sickness certification guidelines that were introduced in the UK in 2002 and updated in 2010, developed by the Department for Work and Pensions to support medical practitioners in this context.13
Another type of sickness certification guidelines has been used for many years in the USA.14
Sickness certification cases are common among general practitioners (GPs), and the lack of scientific knowledge to base management of such cases is a large problem.1
The need for useful guidelines has been large, however, so has also the reluctance towards such guidelines been among GPs.1
In addition to the problems outlined in the first paragraph, were those related to the patients' right to equal treatment, to employers' and insurance officers' difficulties to assess the right to sickness benefits and to the previous dramatic increase in sick-leave rates. Involved stakeholders (healthcare, employers, social insurance, the Swedish Medical Association, the Swedish Society of Medicine and the Swedish Association of Local Authorities and Regions, including the county councils responsible for healthcare) agreed on the need for sickness certification guidelines. In 2005, the Swedish government asked the National Board of Health and Welfare and the Social Insurance Agency to develop sickness certification guidelines. The efforts of these two agencies resulted in two sets of recommendations: overarching guidelines covering the principles related to sickness certification and diagnosis-specific guidelines for duration and degree (full or part time) of sick leave for a large number of diagnoses. Unfortunately, there was (and still is) only a very limited knowledge base regarding the need for, or consequences of being on, sick leave for a certain number of days among persons with different conditions and having different work tasks.15 16
Accordingly, the development of the guidelines could not be based on scientific evidence or even on particular studies. Instead, groups of clinicians with well-documented expertise in handling specific diagnoses were asked to give recommendations about the duration and degree of sickness absence for the most prevalent sick-leave diagnoses. Other systems for such guidelines were also scrutinised.13 14
The suggested guidelines were first tested by several GPs and were found to be useful. In October 2007, the guidelines were introduced in the whole country and were made available at the website of the National Board of Health and Welfare.17
Furthermore, the guidelines are continuously updated, for example, recommendations regarding a number of psychiatric disorders were added in May 2008.
Examples of issues in the overarching guidelines are the roles of physicians and social insurance officers; the importance of patients' participation in the discussion about sick leave; that the diagnosis-specific recommendations and special circumstances might be considered for the patient; to handle sickness certification as an active measure with a clear aim and that the patient, when possible, should keep in contact with the work site; and that it is not the disease in itself but the work incapacity resulting from the disease that can motivate sickness benefits. Furthermore, aspects of qulaity assurance are included.
Below, two examples from the diagnosis-specific guidelines are given. Regarding sickness certification with acute lumbago (ICD-10 code M54-55), it is stated that there is no scientific evidence that heavy work prolongs the rehabilitation or implies a risk for future disorders and complications. The work capacity might be reduced for up to 2 weeks if the patient has a physically strenuous work and otherwise for up to 1 week. Several recommendations are also given regarding actions to be taken if the sick leave exceeds these guidelines. Another example is acute appendicitis (ICD-10 code K35, K37); no need for a sickness certificate if the patient does not have a physically straining work (in Sweden, you can have self-certified sick leave for up to 7 days); if the patient has a physically strenuous work, up to 2 weeks sick leave is recommended after a laparoscopic operation and 3 weeks after a traditional operation, when possible for part time.
In Sweden, as in most countries, the physicians have the following tasks regarding consultations involving possible sickness certification: to determine whether the patient has a disease or injury and if it impairs the work capacity in relation to the patient's work demands; together with the patient discuss advantages and disadvantages of being sickness absent; to determine the grade and duration of sick leave; to make an action plan regarding measures needed during sick leave; to determine possible needs for other contacts within healthcare, with employers or other stakeholders and if so, establish such contacts; to issue a certificate that provides sufficient information for the employer or Social Insurance Office (SIO) for their decision about sickness benefits; to document assessments and actions taken. That is, the physician has two roles: as the treating physician of the patient and as a medical expert, providing information for other stakeholders.1 18 19
Our aim was to investigate to what extent GPs used the sickness certification guidelines and how useful they found them, a year after introduction.