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1.  Prevalence of All-Cause and Diagnosis-Specific Disability Pension at the Time of First Coronary Revascularisation: A Population-Based Swedish Cross-Sectional Study 
PLoS ONE  2015;10(1):e0115540.
Background
Although coronary revascularisation by coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) is well documented, scientific knowledge on disability pension (DP) at the time of revascularisation is lacking. The aim was to investigate the prevalence of all-cause and diagnosis-specific DP at the time of a first coronary revascularisation, accounting for socio-demographic and medical factors.
Materials and Methods
A population-based cross-sectional study using Swedish registers was conducted including all 65,676 patients (80% men) who when aged 30–63 years, within 1994–2006, had a first CABG (n = 22,959) or PCI (n = 42,717) and did not have old-age pension. Associations between socio-demographic and medical factors and the probability of DP were estimated by odds ratios (OR) with 95% confidence intervals (CI) using logistic regression analyses.
Findings
The prevalence of DP at time of revascularisation was 24%, mainly due to musculoskeletal diagnoses. Sixty-two percent had had DP for at least four years before the revascularisation. In the multivariable analyses, DP was more common in women (OR: 2.40; 95% CI: 2.29–2.50), older patients (50–63 years); especially men aged 60–63 years with CABG (OR: 4.91; 95% CI: 4.27–5.66), lower educational level; especially men with PCI (OR: 2.96; 95% CI: 2.69–3.26), patients born outside Sweden; especially men with PCI (OR: 2.11; 95% CI: 1.96–2.27), and in women with an indication of other diagnoses than acute coronary syndrome (ACS) or stable angina pectoris for PCI (OR: 1.72; 95% CI: 1.31–2.24).
Conclusion
About a quarter had DP at the time of revascularisation, often due to musculoskeletal diagnoses. More than half had had DP for at least four years before the intervention. DP was associated with female gender, older age, lower educational level, and being born outside Sweden.
doi:10.1371/journal.pone.0115540
PMCID: PMC4309573  PMID: 25629517
2.  Psychiatric Diagnoses and Risk of Suicidal Behaviour in Young Disability Pensioners: Prospective Cohort Studies of All 19-23 Year Olds in Sweden in 1995, 2000, and 2005, Respectively 
PLoS ONE  2014;9(11):e111618.
Objective
Increasing rates of disability pension (DP) have been observed among young adults. We studied specific psychiatric DP diagnoses and subsequent risk of suicidal behaviour in a series of three cohorts of young adult in Sweden.
Method
In a nationwide register study, we included all young adults who in 1995, 2000, and 2005, respectively, were 19–23 years old and lived in Sweden (n≈500,000 per cohort). Rates of DP and specific psychiatric DP diagnoses were recorded in each cohort. Hazard ratios (HRs) and 95% confidence intervals (CIs) for suicidal behaviour during the following five years, with the corresponding age group as reference, were calculated by Cox proportional hazard regression, adjusted for demographic variables and previous own and parental suicidal behaviour.
Results
The overall proportion with DP in this age group increased from 0.92% in 1995 to 2.29% in 2005, with particularly large increases in psychiatric diagnoses such as hyperkinetic disorders, pervasive developmental disorders, and depression/anxiety. The overall proportion of young disability pensioners attempting suicide during the five-year follow-up increased from 2.21% in the 1995 cohort to 3.81% in the 2005 cohort. Within most psychiatric DP diagnoses, the risk of attempted suicide did not change significantly over time, whereas suicide attempts increased in the reference group. Accordingly, the HRs for suicide attempt decreased in some psychiatric DP diagnoses. The highest adjusted HRs were observed for depression/anxiety (16.41; CI: 9.06 to 29.74) and schizophrenia (9.37; 6.13 to 14.31) in the 1995 cohort. The rate of suicide among young disability pensioners during follow-up ranged from 0.19% in 1995 to 0.37% in 2005, mainly occurring in individuals with psychiatric diagnoses.
Conclusion
Suicidal behaviour has become more prevalent among young disability pensioners, which co-occurred with an increased tendency to grant DP in psychiatric diagnoses with a known high risk of suicidal behaviour. Preventive measures are warranted.
doi:10.1371/journal.pone.0111618
PMCID: PMC4218787  PMID: 25365217
3.  Psychiatric Diagnoses, Medication and Risk for Disability Pension in Multiple Sclerosis Patients; a Population-Based Register Study 
PLoS ONE  2014;9(8):e104165.
Background
Psychiatric comorbidity is common among multiple sclerosis (MS) patients. The majority of MS patients of working ages are on disability pension. The aims of this study were to chart the prevalences of psychiatric diagnoses and medications among MS patients of working ages, and to investigate their association with the risk for future disability pension.
Methods
This nationwide, population-based prospective cohort study includes 10,750 MS patients and 5,553,141 non-MS individuals who in 2005 were aged 17–64 years. Psychiatric diagnoses and medications were identified using nationwide registers. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated adjusting for socio-demographics. Furthermore, a survival analysis with five-year follow-up was performed among the 4,571 MS patients not on disability pension in 2005, with psychiatric diagnoses and medication as risk factors, and disability pension as the outcome.
Results
Among MS patients, 35% had been prescribed psychiatric medication compared to 10% of non-MS individuals, adjusted OR 3.72 (95% CI 3.57 to 3.88). Ten percent of MS patients had received a psychiatric diagnosis, compared to 5.7% of non-MS individuals, OR 1.82 (95% CI 1.71 to 1.94). Serotonin reuptake inhibitors (SSRIs), were the most commonly prescribed drugs (17%) among MS patients, while depression (4.8%) was the most common psychiatric diagnosis. In the survival analysis, MS patients with any psychiatric diagnosis had a hazard ratio (HR) of 1.83 (95% CI 1.53 to 2.18) for disability pension compared to other MS patients. MS patients with any psychiatric drug prescription had a HR for disability pension of 2.09 (95% CI 1.84 to 2.33).
Conclusion
Psychiatric diagnoses and medications are common among MS patients and adversely affect risk for disability pension. This highlights the importance of correct diagnosis and management of psychiatric comorbidity, in a clinical as well as in a societal perspective.
doi:10.1371/journal.pone.0104165
PMCID: PMC4122497  PMID: 25093730
4.  Associations between number of sick-leave days and future all-cause and cause-specific mortality: a population-based cohort study 
BMC Public Health  2014;14:733.
Background
As 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.
Methods
A 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.
Results
A 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.
Conclusion
Even 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.
doi:10.1186/1471-2458-14-733
PMCID: PMC4223521  PMID: 25037232
Mortality; Sick-leave days; Socioeconomic status; Gender; Morbidity; Inpatient care
5.  Associations between Childbirth, Hospitalization and Disability Pension: A Cohort Study of Female Twins 
PLoS ONE  2014;9(7):e101566.
Background
As the literature on long-term effects of childbirth on risk of morbidity or permanent work incapacity (DP) is limited, we aimed to study associations of childbirth with hospitalization and DP, adjusting for familial factors.
Methods
This cohort study included female twins, i.e. women with twin sister, born 1959–1990 in Sweden (n = 5 118). At least one in the twin pair had their first childbirth 1994–2009. Women were followed regarding all-cause and cause-specific (mental or musculoskeletal diagnoses) DP during year 2–5 after first delivery or equivalent. Associations between childbirth, hospitalization and DP were calculated as hazard ratios (HR) with 95% confidence intervals (CI).
Results
Women who did not give birth had markedly higher number of DP days/year compared to those giving birth. Hospitalization after first childbirth was associated with a higher HR of DP. Those hospitalized at least once after their first childbirth had a three-fold DP risk (HR: 3.2; 95% CI 1.1–9.6), DP due to mental diagnoses (HR: 3.2; 1.2–8.8), and of DP due to musculoskeletal diagnoses (HR: 6.1; 1.6–22.9). Lower HRs in the discordant twin pair analyses indicated that familial factors may influence the studied associations.
Conclusions
Women who did not give birth had a much higher risk for DP than those who did. Among those who gave birth, the risk for DP was markedly higher among those with a previous hospitalization, and especially in women with repeated hospitalizations. The results indicate a health selection into giving birth as well as the importance of morbidity for DP.
doi:10.1371/journal.pone.0101566
PMCID: PMC4084814  PMID: 24999632
6.  Co-morbidities increase the risk of disability pension among MS patients: a population-based nationwide cohort study 
BMC Neurology  2014;14:117.
Background
Multiple sclerosis (MS) is a chronic and often disabling disease. In 2005, 62% of the MS patients in Sweden aged 16–65 years were on disability pension. The objective of this study is to investigate whether the presence of common co-morbidities increase MS patients’ risk for disability pension.
Methods
This population-based cohort study included 4 519 MS patients and 4 972 174 non-MS patients who in 2005 were aged 17–64 years, lived in Sweden, and were not on disability pension. Patients with MS were identified in the nationwide in- and outpatient registers, while four different registers were used to construct three sets of measures of musculoskeletal, mental, and cardiovascular disorders. Time-dependent proportional hazard models with a five-year follow up were performed, adjusting for socio-demographic factors.
Results
All studied disorders were elevated among MS patients, regardless of type of measure used. MS patients with mental disorders had a higher risk for disability pension than MS patients with no such co-morbidities. Moreover, mental disorders had a synergistic influence on MS patients’ risk for disability pension. These findings were also confirmed when conducting sensitivity analyses. Musculoskeletal disorders appeared to increase MS patients’ risk for disability pension. The results with regard to musculoskeletal disorders’ synergistic influence on disability pension were however inconclusive. Cardiovascular co-morbidity had no significant influence on MS-patients’ risk for disability pension.
Conclusions
Co-morbidities, especially mental disorders, significantly contribute to MS patients’ risk of disability pension, a finding of relevance for MS management and treatment.
doi:10.1186/1471-2377-14-117
PMCID: PMC4055212  PMID: 24894415
Multiple sclerosis; Co-morbidity; Disability pension; Sick leave; Synergistic effects; Insurance medicine
7.  Risk Factors for Suicidal Behaviour in Individuals on Disability Pension Due to Common Mental Disorders - A Nationwide Register-Based Prospective Cohort Study in Sweden 
PLoS ONE  2014;9(5):e98497.
Background
Common mental disorders (CMD) have become one of the leading causes for disability pension (DP). Studies on predictors of adverse health outcome following DP are sparse. This study aimed to examine the association of different socio-demographic factors and health care consumption with subsequent suicidal behaviour among individuals on DP due to CMD.
Method
This is a population-based prospective cohort study based on register data. All individuals aged 18–64 years, living in Sweden on 31-Dec-2004 who in 2005 were on DP due to CMD (N = 46 745) were followed regarding suicide attempt and suicide (2006–10). Univariate and multivariate hazard ratios (HR) and 95% confidence intervals (CI) for suicidal behaviour were estimated by Cox regression.
Results
During the five-year follow-up, 1 046 (2.2%) and 210 (0.4%) individuals attempted and committed suicide, respectively. Multivariate analyses showed that young age (18–24 years) and low education predicted suicide attempt, while living alone was associated with both higher suicide attempt and suicide (range of HRs 1.23 to 1.68). Combined prescription of antidepressants with anxiolytics during 2005 and inpatient care due to mental diagnoses or suicide attempt (2001–05) were strongly associated with suicide attempt and suicide (range of HRs 1.3 to 4.9), while inpatient care due to somatic diagnoses and specialized outpatient care due to mental diagnoses during 2001–05 only predicted suicide attempt (HR 1.45; 95% CI: 1.3–1.7; HR 1.30; 95% CI: 1.1–1.7).
Conclusions
Along with socio-demographic factors, it is very important to consider type of previous healthcare use and medication history when designing further research or intervention aiming at individuals on DP due to CMD. Further research is warranted to investigate both characteristics of disability pension due to CMD, like duration, diagnoses and grade as well as mechanisms to subsequent suicidal behavior, taking potential gender differences into consideration.
doi:10.1371/journal.pone.0098497
PMCID: PMC4037205  PMID: 24869674
8.  Sickness absence and disability pension due to otoaudiological diagnoses: risk of premature death – a nationwide prospective cohort study 
BMC Public Health  2014;14:137.
Background
It is estimated that hearing difficulties will be one of the top ten leading burdens of disease by 2030. Knowledge of mortality among individuals on sick leave or disability pension due to hearing diagnoses is virtually non-existent. We aimed prospectively to examine the associations of diagnosis-specific sick leave and disability pension due to different otoaudiological diagnoses with risks of all-cause and cause-specific mortality.
Methods
A cohort, based on Swedish registry data, including all 5 248 672 individuals living in Sweden in 2005, aged 20–64, and not on old-age pension, was followed through 2010. Otoaudiological diagnoses were placed in the following categories: otological, hearing, vertigo, and tinnitus. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazard models; individuals on sick leave or disability pension due to different otoaudiological diagnoses during 2005 were compared with those not on sick leave or disability pension.
Results
In multivariable models, individuals with sickness absence due to otoaudiological diagnoses showed a lower risk of mortality, while individuals on disability pension due to otoaudiological diagnoses showed a 14% (95% CI 1-29%) increased risk of mortality, compared with individuals not on sick leave or disability pension. The risk increase among individuals on disability pension was largely attributable to otological (HR 1.56; 95% CI = 1.04-2.33) and hearing diagnoses (HR 1.20; 95% CI = 1.00-1.43).
Conclusion
This large nationwide population-based cohort study suggests an increased risk of mortality among individuals on disability pension due to otoaudiological diagnoses.
doi:10.1186/1471-2458-14-137
PMCID: PMC3922186  PMID: 24507477
Hearing diagnoses; Sick-leave; Mortality
9.  Clinically Diagnosed Insomnia and Risk of All-Cause and Diagnosis-Specific Disability Pension: A Nationwide Cohort Study 
Sleep Disorders  2013;2013:209832.
Background. Insomnia and disability pension are major health problems, but few population-based studies have examined the association between insomnia and risk of disability pension. Methods. We conducted a prospective nationwide cohort study based on Swedish population-based registers including all 5,028,922 individuals living in Sweden on December 31, 2004/2005, aged 17–64 years, and not on disability or old age pension. Those having at least one admission/specialist visit with a diagnosis of disorders of initiating and maintaining sleep (insomnias) (ICD-10: G47.0) during 2000/2001–2005 were compared to those with no such inpatient/outpatient care. All-cause and diagnosis-specific incident disability pension were followed from 2006 to 2010. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were estimated by Cox regression. Results. In models adjusted for prior sickness absence, sociodemographic factors, and inpatient/specialized outpatient care, associations between insomnia and increased risks of all-cause disability pension (IRR 1.35, 95% CI 1.09–1.67) and disability pension due to mental diagnoses (IRR 1.86, 95% CI 1.38–2.50) were observed. After further adjustment for insomnia medications these associations disappeared. No associations between insomnia and risk of disability pension due to cancer, circulatory, or musculoskeletal diagnoses were observed. Conclusion. Insomnia seems to be positively associated with all-cause disability pension and disability pension due to mental diagnoses.
doi:10.1155/2013/209832
PMCID: PMC3893809  PMID: 24490078
10.  Register-based data of psychosocial working conditions and occupational groups as predictors of disability pension due to musculoskeletal diagnoses: a prospective cohort study of 24 543 Swedish twins 
Background
Occupations and psychosocial working conditions have rarely been investigated as predictors of disability pension in population-based samples. This study investigated how occupational groups and psychosocial working conditions are associated with future disability pension due to musculoskeletal diagnoses, accounting for familial factors in the associations.
Methods
A sample of 24 543 same-sex Swedish twin individuals was followed from 1993 to 2008 using nationwide registries. Baseline data on occupations were categorized into eight sector-defined occupational groups. These were further used to reflect psychosocial working conditions by applying the job strain scores of a Job Exposure Matrix. Cox proportional hazard ratios (HR) were estimated.
Results
During the 12-year (average) follow-up, 7% of the sample was granted disability pension due to musculoskeletal diagnoses. Workers in health care and social work; agriculture, forestry and fishing; transportation; production and mining; and the service and military work sectors were two to three times more likely to receive a disability pension than those in the administration and management sector. Each single unit decrease in job demands and each single unit increase in job control and social support significantly predicted disability pension. Individuals with high work strain or an active job had a lower hazard ratio of disability pension, whereas a passive job predicted a significantly higher hazard ratio. Accounting for familial confounding did not alter these results.
Conclusion
Occupational groups and psychosocial working conditions seem to be independent of familial confounding, and hence represent risk factors for disability pension due to musculoskeletal diagnoses. This means that preventive measures in these sector-defined occupational groups and specific psychosocial working conditions might prevent disability pension due to musculoskeletal diagnoses.
doi:10.1186/1471-2474-14-268
PMCID: PMC3849955  PMID: 24040914
Sick leave; Disability pension; Psychosocial working conditions; Occupational group; Musculoskeletal disorder; Twin
11.  Sickness absence due to otoaudiological diagnoses; a descriptive nationwide study 
BMC Public Health  2013;13:635.
Background
Hearing difficulties constitute a large public health problem. Knowledge about their consequences in terms of sickness absence due to otoaudiological diagnoses is very scarce. The aim of this study was to gain such knowledge. Both individuals with sick leave due to otoaudiological diagnoses and sick-leave spells due to these diagnoses were examined, in a nationwide setting.
Methods
Through Swedish nationwide registers we identified all 4768 individuals, aged 16–64 years and living in Sweden who were sickness absent due to otoaudiological diagnoses (ICD10; H60-H95) in 2005. We described the demographic characteristics of these individuals, as well as aspects regarding prevalence and duration of such sick-leave spells, in general and in four specific diagnosis groups; otological, hearing, vertigo, and tinnitus.
Results
Sick leave due to otoaudiological diagnoses was more common among women in all diagnosis groups except with tinnitus. Individuals with a hearing or tinnitus sick-leave diagnosis had a higher educational level and were hospitalized fewer days compared to those sickness absent due to vertigo or otological diagnoses. Particularly, sick-leave spells due to hearing or tinnitus diagnoses tended to be long, in many cases lasting the entire year. The majority of the individuals only had one sick-leave spell in 2005.
Conclusions
Although the actual number of individuals with a sick-leave spell due to specific otoaudiological diagnosis might not be considered high, the high prevalence of long sick-leave spells due to particularly hearing and tinnitus diagnoses indicates the importance of preventive and rehabilitative actions.
doi:10.1186/1471-2458-13-635
PMCID: PMC3733665  PMID: 23835212
Otoaudiological diagnoses; Hearing difficulties; Sick leave
12.  A prospective cohort study of disability pension due to mental diagnoses: the importance of health factors and behaviors 
BMC Public Health  2013;13:621.
Background
Previous studies have found associations between various health factors and behaviors and mental disorders. However, knowledge of such associations with disability pension (DP) due to mental diagnoses is scarce. Moreover, the influence of familial factors (genetics and family background) on the associations are mainly unknown. The aim of the study was to investigate associations between health factors and behaviors and future DP due to mental diagnoses in a twin cohort, accounting for familial confounding.
Methods
A prospective cohort study of Swedish twins (N=28 613), including survey data and national register data on DP and other background factors was conducted. Cox proportional hazards regression models were used to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the whole twin cohort, and for discordant twin pairs.
Results
During follow-up 1998–2008 (median 10 years), 2.2% of the cohort was granted a DP with a mental diagnosis. In the fully adjusted analyses of the whole cohort, the associations of poor or moderate self-rated health (SRH), under- or overweight, former or current tobacco use, or being an abstainer from alcohol were significantly associated with risk of DP due to mental diagnoses. Analyses of discordant twin pairs confirmed all these associations, except for current tobacco use, being independent from familial confounding. Exclusion of individuals with current or previous depression or anxiety at baseline did not influence the associations found.
Conclusions
Poor or moderate SRH, under- or overweight, former tobacco use or being an abstainer from alcohol seem to be strong direct predictors of DP due to mental diagnoses, independently of several confounders of this study, including familial factors.
doi:10.1186/1471-2458-13-621
PMCID: PMC3733696  PMID: 23816331
Sick leave; Disability pension; Mental disorders; Self-rated health; Life-style; Twins
13.  Health care management of sickness certification tasks: results from two surveys to physicians 
BMC Research Notes  2013;6:207.
Background
Health care in general and physicians in particular, play an important role in patients’ sickness certification processes. However, a lack of management within health care regarding how sickness certification is carried out has been identified in Sweden. A variety of interventions to increase the quality of sickness certification were introduced by the government and County Councils. Some of these measures were specifically aimed at strengthening health care management of sickness certification; e.g. policy making and management support. The aim was to describe to what extent physicians in different medical specialties had access to a joint policy regarding sickness certification in their clinical settings and experienced management support in carrying out sickness certification.
Method
A descriptive study, based on data from two cross-sectional questionnaires sent to all physicians in the Stockholm County regarding their sickness certification practice. Criteria for inclusion in this study were working in a clinical setting, being a board-certified specialist, <65 years of age, and having sickness certification consultations at least a few times a year. These criteria were met by 2497 physicians in 2004 and 2204 physicians in 2008. Proportions were calculated regarding access to policy and management support, stratified according to medical specialty.
Results
The proportions of physicians working in clinical settings with a well-established policy regarding sickness certification were generally low both in 2004 and 2008, but varied greatly between different types of medical specialties (from 6.1% to 46.9%). Also, reports of access to substantial management support regarding sickness certification varied greatly between medical specialties (from 10.5% to 48.8%). More than one third of the physicians reported having no such management support.
Conclusions
Most physicians did not work in a clinical setting with a well-established policy on sickness certification tasks, nor did they experience substantial support from their manager. The results indicate a need of strengthening health care management of sickness certification tasks in order to better support physicians in these tasks.
doi:10.1186/1756-0500-6-207
PMCID: PMC3671141  PMID: 23701711
Health care management; Sickness certification practice; Sick leave; Physician
14.  Reasons for and factors associated with issuing sickness certificates for longer periods than necessary: results from a nationwide survey of physicians 
BMC Public Health  2013;13:478.
Background
Physicians’ 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.
Methods
In 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.
Results
The 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.
Conclusions
This 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.
doi:10.1186/1471-2458-13-478
PMCID: PMC3691717  PMID: 23679866
Sick leave; Sickness certification; Insurance medicine; Physician
15.  Lack of Adjustment Latitude at Work as a Trigger of Taking Sick Leave—A Swedish Case-Crossover Study 
PLoS ONE  2013;8(4):e61830.
Objectives
Research has shown that individuals reporting a low level of adjustment latitude, defined as having few possibilities to temporarily adjust work demands to illness, have a higher risk of sick leave. To what extent lack of adjustment latitude influences the individual when making the decision to take sick leave is unknown. We hypothesize that ill individuals are more likely to take sick leave on days when they experience a lack of adjustment latitude at work than on days with access to adjustment latitude.
Methods
A case-crossover design was applied to 546 sick-leave spells, extracted from a cohort of 1 430 employees at six Swedish workplaces, with a 3–12 month follow-up of all new sick-leave spells. Exposure to lack of adjustment latitude on the first sick-leave day was compared with exposure during several types of control periods sampled from the previous two months for the same individual.
Results
Only 35% of the respondents reported variations in access to adjustment latitude, and 19% reported a constant lack of adjustment latitude during the two weeks prior to the sick-leave spell. Among those that did report variation, the risk of sick leave was lower on days with lack of adjustment latitude, than on days with access (Odds Ratio 0.36, 95% Confidence Interval 0.25–0.52).
Conclusions
This is the first study to show the influence of adjustment latitude on the decision to take sick leave. Among those with variations in exposure, lack of adjustment latitude was a deterrent of sick leave, which is contrary to the à priori hypothesis. These results indicate that adjustment latitude may not only capture long-lasting effects of a flexible working environment, but also temporary possibilities to adjust work to being absent. Further studies are needed to disentangle the causal mechanisms of adjustment latitude on sick-leave.
doi:10.1371/journal.pone.0061830
PMCID: PMC3631183  PMID: 23620792
16.  Does feeling respected influence return to work? Cross-sectional study on sick-listed patients’ experiences of encounters with social insurance office staff 
BMC Public Health  2013;13:268.
Background
Previous research shows that how patients perceive encounters with healthcare staff may affect their health and self-estimated ability to return to work. The aim of the present study was to explore long-term sick-listed patients’ encounters with social insurance office staff and the impact of these encounters on self-estimated ability to return to work.
Methods
A random sample of long-term sick-listed patients (n = 10,042) received a questionnaire containing questions about their experiences of positive and negative encounters and item lists specifying such experiences. Respondents were also asked whether the encounters made them feel respected or wronged and how they estimated the effect of these encounters on their ability to return to work. Statistical analysis was conducted using 95% confidence intervals (CI) for proportions, and attributable risk (AR) with 95% CI.
Results
The response rate was 58%. Encounter items strongly associated with feeling respected were, among others: listened to me, believed me, and answered my questions. Encounter items strongly associated with feeling wronged were, among others: did not believe me, doubted my condition, and questioned my motivation to work. Positive encounters facilitated patients’ self-estimated ability to return to work [26.9% (CI: 22.1-31.7)]. This effect was significantly increased if the patients also felt respected [49.3% (CI: 47.5-51.1)]. Negative encounters impeded self-estimated ability to return to work [29.1% (CI: 24.6-33.6)]; when also feeling wronged return to work was significantly further impeded [51.3% (CI: 47.1-55.5)].
Conclusions
Long-term sick-listed patients find that their self-reported ability to return to work is affected by positive and negative encounters with social insurance office staff. This effect is further enhanced by feeling respected or wronged, respectively.
doi:10.1186/1471-2458-13-268
PMCID: PMC3623723  PMID: 23522034
Encounters; Ethics; Long-term sickness absentees; Return to work; Social insurance office staff; Sweden
17.  Diagnosis-specific disability pension predicts suicidal behaviour and mortality in young adults: a nationwide prospective cohort study 
BMJ Open  2013;3(2):e002286.
Objectives
Increasing rates of disability pension (DP), particularly owing to mental diagnoses, have been observed among young adults in Organisation for Economic Co-operation and Development (OECD) countries. There is a lack of knowledge about the health prognosis in this group. The aim of this study was to investigate whether DP in young adulthood owing to specific mental diagnoses or somatic diagnoses predicts suicidal behaviour and all-cause mortality.
Design
A nationwide prospective cohort study.
Setting
A register study of all young adults who in 2005 were 19–23 years old and lived in Sweden. Registers held by the National Board of Health and Welfare, Statistics Sweden and the National Social Insurance Agency were used.
Participants
525 276 young adults. Those who in 2005 had DP with mental diagnoses (n=8070) or somatic diagnoses (n=3975) were compared to all the other young adults in the same age group (n=513 231).
Outcome measures
HRs for suicide attempt, suicide and all-cause mortality in 2006–2010 were calculated by Cox proportionate hazard regression models, adjusted for sex, country of birth, parental education and parental and previous own suicidal behaviour.
Results
The adjusted HR for suicide attempt was 3.32 (95% CI 2.98 to 3.69) among those on DP with mental diagnoses and 1.78 (95% CI 1.41 to 2.26) among those on DP with somatic diagnoses. For the specific mental diagnoses, the unadjusted HRs ranged between 2.42 (mental retardation) and 22.94 (personality disorders), while the adjusted HRs ranged between 2.03 (mental retardation) and 6.00 (bipolar disorder). There was an increased risk of mortality for young adults on DP in general, but only those with mental DP diagnoses had a significantly elevated HR of completed suicide with an adjusted HR of 3.92 (95% CI 2.83 to 5.43).
Conclusions
Young adults on DP are at increased risk of suicidal behaviour and preterm death, which emphasises the need for improved treatment and follow-up.
doi:10.1136/bmjopen-2012-002286
PMCID: PMC3586126  PMID: 23396561
Disability; Suicide; Psychiatry; Registers
18.  Psychiatrists′ work with sickness certification: frequency, experiences and severity of the certification tasks in a national survey in Sweden 
Background
Many 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.
Methods
A 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.
Results
The 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.
Conclusion
The 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.
doi:10.1186/1472-6963-12-362
PMCID: PMC3480832  PMID: 23075202
Sickness certification; Psychiatry; Sick leave; Physician
19.  Self-reported hearing difficulties, main income sources, and socio-economic status; a cross-sectional population-based study in Sweden 
BMC Public Health  2012;12:874.
Background
Hearing difficulties constitute the most common cause of disability globally. Yet, studies on people with hearing difficulties regarding socio-economic status (SES), work, long-term unemployment, sickness absence, and disability pension are scarce. The aim of the present study was to investigate the main income sources of men and women of working ages with and without self-reported hearing difficulties and associations with gender, age, SES, type of living area, and country of birth.
Methods
A cross-sectional population-based study, using information on self-reported hearing difficulties and SES of 19 045 subjects aged 20–64 years participating in Statistics Sweden’s annual Living Conditions Surveys in any of the years 2004 through 2008. The information was linked to a nationwide database containing data on demographics and income sources. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated, using binary logistic regression analysis.
Results
Hearing difficulties increased with age and were more common in men (age-adjusted OR: 1.42 (95% CI: 1.30-1.56)) with an overall prevalence of 13.1% in men and 9.8% in women. Using working men as reference, the OR of having hearing difficulties was 1.23 (0.94-1.60) in men with unemployment benefits and 1.36 (1.13-1.65) in men with sickness benefits or disability pension, when adjusting for age and SES. The corresponding figures in women were 1.59 (1.17-2.16) and 1.73 (1.46-2.06). The OR of having sickness benefits or disability pension in subjects with hearing difficulties was 1.36 (1.12-1.64) in men and 1.70 (1.43-2.01) in women, when adjusting for age and SES and using men and women with no hearing difficulties as reference.
Conclusions
Hearing difficulties were more prevalent in men. After adjustment with age and SES as well as with type of living area and country of birth, a significant association with unemployment benefits was found only in women, and the associations with long-term sickness absence and disability pension tended to be stronger in women.
doi:10.1186/1471-2458-12-874
PMCID: PMC3533986  PMID: 23067045
Disability pension; Hearing loss; Occupation; Self-reported health; Sick leave; Socio-demographic factors; Socio-economic status; Unemployment; Working
20.  Differences in the association between sickness absence and long-term sub-optimal health by occupational position: a 14-year follow-up in the GAZEL cohort 
Objectives
Although sickness absence is a strong predictor of health, little work has examined whether this association varies by occupational position. The aim of this study was to investigate overall and diagnosis-specific sickness absence as a predictor of future long-term sub-optimal health by occupational position.
Methods
Prospective occupational cohort study; 15,320 employees (73% men) aged 37–51. Sickness absences (1990–1992), including 13 diagnostic categories, were examined by occupational position, based on employment grade, in relation to self-rated health measured annually 1993–2006.
Results
60% of employees in higher grade and 22% in lower grade occupations had no sickness absence. Conversely, 40% of employees in lower grade and 9.5% in higher grade occupations had over 30 sick-leave days. Repeated-measures logistic regression analyses adjusted for age, sex, and chronic disease showed employees with over 30 days absence, compared to those with no absence, had approximately double the risk of suboptimal health over the 14-year follow-up in all occupational positions. However, 1–30 days sick-leave was associated with greater odds of suboptimal health in the high; odds ratio 1.48, 95% confidence intervals (1.27–1.72) and intermediate 1.29 (1.15–1.45), but not lower grade occupations 1.06 (0.82–1.38). Differences by occupational position in the association between sickness absence in 13 specific diagnostic categories and sub-optimal health over the ensuing 14 years were limited to stronger associations observed with cancer and mental disorders in the higher grades.
Conclusions
The association between sickness absence of over 30 days a year and future long-term self-rated health appears to differ little by occupational position.
doi:10.1136/oem.2010.060210
PMCID: PMC3186885  PMID: 21242277
Sickness absence; sick leave; self-rated health; longitudinal; multi-level; occupational position
21.  Differences in the association between sickness absence and long-term sub-optimal health by occupational position: a 14-year follow-up in the GAZEL cohort 
Objectives
Although sickness absence is a strong predictor of health, little work has examined whether this association varies by occupational position. The aim of this study was to investigate overall and diagnosis-specific sickness absence as a predictor of future long-term sub-optimal health by occupational position.
Methods
Prospective occupational cohort study; 15,320 employees (73% men) aged 37–51. Sickness absences (1990–1992), including 13 diagnostic categories, were examined by occupational position, in relation to self-rated health measured annually 1993–2006.
Results
60% of employees in higher occupational position and 22% in lower position had no sickness absence. Conversely, 9.5% of employees in higher position and 40% in lower occupational position had over 30 sick-leave days. Repeated-measures logistic regression analyses adjusted for age, sex, and chronic disease showed employees with over 30 days absence, compared to those with no absence, had approximately double the risk of suboptimal health over the 14-year follow-up in all occupational positions. However, 1–30 days sick-leave was associated with greater odds of suboptimal health in the high; odds ratio 1.48, 95% confidence intervals (1.27–1.72) and intermediate 1.29 (1.15–1.45), but not lower occupational positions 1.06 (0.82–1.38). Differences by occupational position in the association between sickness absence in 13 specific diagnostic categories and sub-optimal health over the ensuing 14 years were limited to stronger associations observed with cancer and mental disorders in the higher occupational positions.
Conclusions
The association between sickness absence of over 30 days a year and future long-term self-rated health appears to differ little by occupational position.
doi:10.1136/oem.2010.060210
PMCID: PMC3186885  PMID: 21242277
Adult; Female; Follow-Up Studies; France; epidemiology; Health Status; Humans; Male; Middle Aged; Occupational Diseases; epidemiology; Occupational Health; statistics & numerical data; Occupations; Prospective Studies; Risk Factors; Sick Leave; statistics & numerical data; Social Class; Sickness absence; sick leave; health; longitudinal; multi-level; occupational position
22.  Sickness Absence Due to Specific Mental Diagnoses and All-Cause and Cause-Specific Mortality: A Cohort Study of 4.9 Million Inhabitants of Sweden 
PLoS ONE  2012;7(9):e45788.
Background
Despite the magnitude and increase of sickness absence due to mental diagnoses, little is known regarding long-term health outcomes. The aim of this nationwide population-based, prospective cohort study was to investigate the association between sickness absence due to specific mental diagnoses and the risk of all-cause and cause-specific mortality.
Methods
A cohort of all 4 857 943 individuals living in Sweden on 31.12.2004 (aged 16–64 years, not sickness absent, or on retirement or disability pension), was followed from 01.01.2005 through 31.12.2008 for all-cause and cause-specific mortality (suicide, cancer, circulatory disease) through linkage of individual register data. Individuals with at least one new sick-leave spell with a mental diagnosis in 2005 were compared to individuals with no sickness absence. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated by Cox regression, adjusting for age, sex, education, country of birth, family situation, area of residence, and pre-existing morbidity (diagnosis-specific hospital inpatient (2000–2005) and outpatient (2001–2005) care).
Results
In the multivariate analyses, mental sickness absence in 2005 was associated with an increased risk for all-cause mortality: HR: 1.65, 95% CI: 1.47–1.86 in women and in men: 1.73, 1.57–1.91; for suicide, cancer (both smoking and non-smoking related) as well as mortality due to circulatory disease only in men. Estimates for cause-specific mortality ranged from 1.48 to 3.37. Associations with all-cause mortality were found for all mental sickness absence diagnostic groups studied.
Conclusions
Knowledge about the prognosis of patients sickness absent with specific mental diagnoses is of crucial clinical importance in health care. Sickness absence due to specific mental diagnoses may here be used as a risk indictor for subsequent mortality.
doi:10.1371/journal.pone.0045788
PMCID: PMC3458091  PMID: 23049861
23.  Hearing difficulties, ear-related diagnoses and sickness absence or disability pension - a systematic literature review 
BMC Public Health  2012;12:772.
Background
Hearing difficulties is a large public health problem, prognosticated to be the ninth leading burden of disease in 2030, and may also involve large consequences for work capacity. However, research regarding sickness absence and disability pension in relation to hearing difficulties is scarce. The aim was to gain knowledge about hearing difficulties or other ear-related diagnoses and sickness absence and disability pension through conducting a systematic literature review of published studies.
Methods
Studies presenting empirical data on hearing difficulties or ear-related diagnoses and sick leave or disability pension, published in scientific peer-reviewed journals, were included. Studies were sought for in three ways: in literature databases (Pub-Med, Embase, PsycInfo, SSCI, and Cochrane) through March 2011, through scrutinising lists of references, and through contacts. Identified publications were assessed for relevance and data was extracted from the studies deemed relevant.
Results
A total of 18 studies were assessed as relevant and included in this review, regardless of scientific quality. Fourteen studies presented empirical data on hearing difficulties/ear diagnoses and sick leave and six on these conditions and disability pension. Only two studies presented rate ratios or odds ratios regarding associations between hearing difficulties and sick leave, and only two on hearing difficulties and risk of disability pension. Both measures of hearing difficulties and of sick leave varied considerable between the studies.
Conclusions
Remarkably few studies on hearing difficulties in relation to sickness absence or disability pension were identified. The results presented in them cannot provide evidence for direction or magnitude of potential associations.
doi:10.1186/1471-2458-12-772
PMCID: PMC3560197  PMID: 22966953
Sick leave; Disability pension; Hearing difficulties; Systematic literature review
24.  Sickness Presenteeism Predicts Suboptimal Self-Rated Health and Sickness Absence: A Nationally Representative Study of the Swedish Working Population 
PLoS ONE  2012;7(9):e44721.
Background
Earlier studies have suggested that sickness presenteeism (SP) may be a risk factor for future health problems. The purpose of the present study was to test this in a nationally representative prospective study of Swedish workers.
Methods
Prospective cohort with a representative sample of the Swedish working population surveyed in 2008 and 2010. Odds ratios (OR) with 95% confidence intervals (CI) were calculated using logistic regression.
Results
Those who reported more than 7 days of SP had higher risk of suboptimal SRH compared to those who reported no SP (OR = 5.95; 95% CI 4.98–7.12), also after adjustment for confounders (OR = 1.64; 95% CI 1.30–2.06). Those who reported 1–7 days of SP also had an increased risk before and after adjustments. Inclusion of self-rated physical and psychological work capacity did not attenuate the associations, whereas of emotional exhaustion attenuated the ORs to non-significance for both outcomes, indicating that the health consequences associated with SP are largely related to mental health.
Conclusion
The results strengthen earlier findings suggesting that SP can be a risk factor for future suboptimal general health and sickness absence, particularly through mental health problems. This indicates that asking about SP could yield important information for employers, occupational health practitioners and GPs, possibly leading to more timely intervention that could decrease the risk of future sickness absence and more serious health problems, especially in the mental domain. Further studies of the possible causal pathways between SP and future health development are also warranted, especially since going to work is often seen as desirable also for those with poor health.
doi:10.1371/journal.pone.0044721
PMCID: PMC3439368  PMID: 22984547
25.  Activities and sources of income after a period of long-term sick leave - a population-based prospective cohort study 
BMC Public Health  2012;12:745.
Background
There is limited knowledge about what happens to people after long-term sick leave. The aim of this report was to conduct a prospective study of individuals who were on prolonged sick leave during a particular year, considering their activities and sources of income during subsequent years. To enable comparison of different time periods, we used three cohorts of individuals with different starting years.
Methods
Using data from national registers, three separate cohorts were constructed that included all people living in Sweden who were 20-64 years of age (>5 million) in the years 1995, 2000 and 2005, respectively. The individual members of the cohorts were classified into the following groups based on their main source of income and activity in 1995-2008: on long-term sick leave, employed, old-age pensioner, long-term unemployed, disability pensioner, on parental leave, social assistance recipient, student allowance recipient, deceased, or emigrated.
Results
Most individuals on long-term (> 6 months) sick leave in 1995 were not employed 13 years later. Only 11% of the women and 13% of the men were primarily in employment after 13 years. Instead, a wide range of alternatives existed, for example, many had been granted disability pension, and about 10% of the women and 17% of the men had died during the follow-up period. A larger proportion of those with long-term sick leave were back in employment when 2005 was the starting year for the follow-up.
Conclusions
The low future employment rates for people on long-term sick leave may seem surprising. There are several possible explanations for the finding: The disorders these people may have, might have entailed longstanding difficulties on the labor market. Besides, long-term absence from work, no matter what its causes were, might have worsen the chances of further employment. The economic cycles may also have been of importance. The improving labor market during later years seems to have improved the chances for employment among those earlier on long-term sick leave.
doi:10.1186/1471-2458-12-745
PMCID: PMC3519645  PMID: 22950458

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