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1.  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
2.  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
3.  Quality of sickness certification in primary health care: a retrospective database study 
BMC Family Practice  2013;14:48.
Background
In the period 2004–2009, national and regional initiatives were developed in Sweden to improve the quality of sickness certificates. Parameters for assessing the quality of sickness certificates in primary health care have been proposed. The aim of this study was to measure the quality of sickness certification in primary health care by means of assessing sickness certificates issued between 2004 and 2009 in Stockholm.
Methods
This was a retrospective study using data retrieved from sickness certificates contained in the electronic patient records of 21 primary health care centres in Stockholm County covering six consecutive years. A total number of 236 441 certificates were used in the current study. Seven quality parameters were chosen as outcome measures. Descriptive statistics and regression models with time, sex and age group as explanatory variables were used.
Results
During the study period, the quality of the sickness certification practice improved as the number of days on first certification decreased and the proportion of duly completely and acceptable certificates increased. Assessment of need for vocational rehabilitation and giving a prognosis for return to work were not significantly improved during the same period. Time was the most influential variable.
Conclusions
The quality of sickness certification practice improved for most of the parameters, although additional efforts to improve the quality of sickness certificates are needed. Measures, such as reminders, compulsory certificate fields and structured guidance, could be useful tools to achieve this objective.
doi:10.1186/1471-2296-14-48
PMCID: PMC3637144  PMID: 23586694
General practitioners; Sick leave; Sickness certificates; Quality indicators; Health care
4.  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
5.  Sickness certification as a complex professional and collaborative activity - a qualitative study 
BMC Public Health  2012;12:702.
Background
Physicians have an important but problematic task to issue sickness certifications. A manifold of studies have identified a wide spectrum of medical and insurance-related problems in sickness certification. Despite educational efforts aiming to improve physicians’ knowledge of social insurance medicine there are no signs of reduction of these problems. We hypothesised that the quality deficits is not only due to lack of knowledge among issuing physicians. The aim of the study was to explore physicians’ challenges when handling sickness certification in relation to their professional roles as physicians and to their interaction with different stakeholders.
Methods
One hundred seventy-seven physicians in Stockholm County, Sweden, participated in a sick-listing audit program. Participants identified challenges in handling sick-leave issues and formulated action plans for improvement. Challenges and responsible stakeholders were identified in the action plans. To deepen the understanding facilitators of the program were interviewed. A qualitative content analysis was performed exploring challenge categories and categories of stakeholders with responsibility to initiate actions to improve the quality of the sick-listing process. The challenge categories were then related by their content to professional competence roles in accord with the Canadian Medical Education Directions for Specialists (CanMEDS) framework and to the stakeholder categories.
Results
Seven categories of challenges were identified. Practitioner patient interaction, Work capacity assessment, Interaction with the Social Insurance Administration, The patient’s workplace and the labour market, Sick-listing practice, Collaboration and resource allocation within the Health Care System, Leadership and routines at the Health Care Unit. The challenges were related to all seven CanMEDS roles. Five categories of stakeholders were identified and several stakeholders were involved in each challenge category.
Conclusions
Physicians performing sickness certification tasks experience a complex variety of challenges. From physician perspective actions to handle these need to be initiated in interaction with both medical and non-medical stakeholders. The relation between the challenges and a well-established professional competence framework revealed a complex pattern. Thus, from a public health perspective, educational activities aimed to improve the sick-listing process should address all physician competences including identification and interaction with stakeholders, and not just knowledge of social insurance medicine.
doi:10.1186/1471-2458-12-702
PMCID: PMC3499228  PMID: 22928773
6.  Physicians who experience sickness certification as a work environmental problem: where do they work and what specific problems do they have? A nationwide survey in Sweden 
BMJ Open  2012;2(2):e000704.
Objectives
In a recent study, 11% of the Swedish physicians below 65 years dealing with sickness certification tasks (SCT) experienced SCT to a great extent as a work environment problem (WEP). This study aimed at exploring which SCT problems those physicians experienced and if these problems varied between general practitioners (GPs), psychiatrists, orthopaedists and physicians working at other types of clinics.
Design
A cross-sectional nationwide questionnaire study.
Setting
All physicians working in Sweden in 2008.
Participants
The 1554 physicians <65 years old, working in a clinical setting, having SCT and stating SCT to a great extent being a WEP.
Outcome measures
Frequency of possibly problematic situations or lack of time, reasons for sickness certifying unnecessarily long, experience of difficulties in contacts with sickness insurance offices, and severity of experienced problems.
Results
In all, 79% of this group of physicians experienced SCT as problematic at least once weekly, significantly higher proportion among GPs (p<0.001) and psychiatrists (p=0.005). A majority (at most 68.3%) experienced lack of time daily, when handling SCT, the proportion being significantly higher among orthopaedists (p=0.003, 0.007 and 0.011 on three respective items about lack of time). Among psychiatrists, a significantly higher proportion (p<0.001) stated wanting a patient coordinator. Also, GPs agreed to a higher extent (p<0.001) to finding 14 different SCT tasks as ‘very problematic’.
Conclusions
The main problem among physicians who experience SCT to a great extent as a WEP was lack of time related to SCT. The proportion of physicians experiencing problems varied in many aspects significantly between the different work clinics; however, GPs were among the highest in most types of problems. The results indicate that measures for improving physicians' sickness certification practices should be focused on organisational as well as professional level and that the needs in these aspects differ between specialties.
Article summary
Article focus
A study of the minority of physicians who state sickness certification tasks to a great extent being a work environment problem.
What problems do these physicians experience in relation to sickness certification?
Do the experienced problems vary with type of work clinic/specialty?
Key messages
A vast majority of these physicians experienced daily lack of time when handling sickness certification tasks.
About half of these physicians found it very problematic to assess level of work incapacity, to manage the two roles as the patient's physician and as a medical expert, and to provide the Social Insurance Office with more extensive sickness certificates.
Measures for improving physicians' sickness certification practices should be focused on organisational as well as professional levels and might need to differ between specialties.
Strengths and limitations of this study
The study was based on a questionnaire sent to all 37 000 physicians in a whole country, and the response rate (61%) could be regarded as relatively high.
Only one question about work environment was included.
doi:10.1136/bmjopen-2011-000704
PMCID: PMC3293140  PMID: 22382120
7.  Use and usefulness of guidelines for sickness certification: results from a national survey of all general practitioners in Sweden 
BMJ Open  2011;1(2):e000303.
Objectives
Diagnoses-specific sickness certification guidelines were recently introduced in Sweden. The aim of this study was to investigate to which extent general practitioners (GPs) used these guidelines and how useful they found them, 1 year after introduction.
Design
A cross-sectional questionnaire study. A comprehensive questionnaire about sickness certification practices in 2008 was sent to all physicians living and working in Sweden (n=36 898, response rate 60.6%). In all, 19.7% (n=4394) of the responders worked as GPs.
Setting
Primary healthcare in all Sweden.
Participants
The participating GPs who had consultations concerning sickness certification at least a few times a year (n=4278, 97%).
Main outcome measures
Descriptive statistics and prevalence ratios for the 11 questionnaire items about the use and usefulness of the sickness certification guidelines.
Results
A majority (76.2%) of the GPs reported that they used the guidelines. In addition, 65.4% and 43.5% of those GPs reported that the guidelines had facilitated their contacts with patients and social insurance officers, respectively. The guidelines also helped nearly one-third (31.5%) of the GPs to develop their competence and improve the quality of their management of sickness certification consultations (33.5%). About half experienced some problems when using the guidelines and 43.7% wanted better competence in using them. A larger proportion of non-specialists and of GPs with fewer sickness certification consultations had benefitted from the guidelines.
Conclusions
The national sickness certification guidelines implemented in Sweden were widely used by GPs already a year after introduction. Also, the GPs consider the guidelines useful in several respects, for example, in patient contacts and for competence development.
Article summary
Article focus
Sweden recently introduced national sickness certification guidelines. We investigated:
To what extent did the general practitioners use them 1 year later?
How useful did the general practitioners find them?
Key messages
Already after 1 year, most general practitioners used the guidelines and benefited extensively from them
Two-thirds of the general practitioners reported that the guidelines had facilitated their patient contacts and one-third that it facilitated their contacts with social insurance, other healthcare staff and employers
One-third stated that the guidelines had been helpful in competence development and improved the quality of their management of sickness certification cases
Strengths and limitations of this study
Strengths were the large study group and that all general practitioners in Sweden were included. Also, internationally this is the, so far, without comparison largest study of general practitioner's sickness certification practices. However, the non-response rate of 39% was a limitation, and we have no way of knowing if the non-responders differed with regard to use of the guidelines. However, only 11 of the 163 items in the questionnaire concerned the guidelines, why there is no reason to believe that no response was related to use of the guidelines.
doi:10.1136/bmjopen-2011-000303
PMCID: PMC3244659  PMID: 22189350
8.  Frequency and severity of problems that general practitioners experience regarding sickness certification 
Objective
Tasks involved in sickness certification constitute potential problems for physicians. The objective in this study was to obtain more detailed knowledge about the problems that general practitioners (GPs) experience in sickness certification cases, specifically regarding reasons for issuing unnecessarily long sick-leave periods.
Design
A cross-sectional national questionnaire study. Setting. Primary health care in Sweden.
Subjects
The 2516 general practitioners (GPs), below 65 years of age, who had consultations involving sickness certification every week. This makes it the by far largest such study worldwide. The response rate among GPs was 59.9%.
Results
Once a week, half of the GPs (54.5%) found it problematic to handle sickness certification, and one-fourth (25.9%) had a patient who wanted to be sickness absent for some reason other than medical work incapacity. Issues rated as problematic by many GPs concerned assessing work capacity, prognosticating the duration of incapacity, handling situations in which the GP and the patient had different opinions on the need for sick leave, and managing the two roles as physician for the patient and medical expert in writing certificates for other authorities. Main reasons for certifying unnecessarily long sick-leave periods were long waiting times in health care and in other organizations, and younger and male GPs more often reported doing this to avoid conflicts with the patient.
Conclusion
A majority of the GPs found sickness certification problematic. Most problems were related to professional competence in insurance medicine. Better possibilities to develop, maintain, and practise such professionalism are warranted.
doi:10.3109/02813432.2011.628235
PMCID: PMC3308465  PMID: 22126222
GP; physicians; primary health care; sickness certification; sick leave
9.  Health problems and disability in long-term sickness absence: ICF coding of medical certificates 
BMC Public Health  2011;11:860.
Background
The purpose of this study was to test the feasibility of International Classification of Functioning, Disability and Health (ICF) and to explore the distribution, including gender differences, of health problems and disabilities as reflected in long-term sickness absence certificates.
Methods
A total of 433 patients with long sick-listing periods, 267 women and 166 men, were included in the study. All certificates exceeding 28 days of sick-listing sent to the local office of the Swedish Social Insurance Administration of a municipality in the Stockholm area were collected during four weeks in 2004-2005. ICD-10 medical diagnosis codes in the certificates were retrieved and free text information on disabilities in body function, body structure or activity and participation were coded according to ICF short version.
Results
In 89.8% of the certificates there were descriptions of disabilities that readily could be classified according to ICF. In a reliability test 123/131 (94%) items of randomly chosen free text information were identically classified by two of the authors. On average 2.4 disability categories (range 0-9) were found per patient; the most frequent were 'Sensation of pain' (35.1% of the patients), 'Emotional functions' (34.1%), 'Energy and drive functions' (22.4%), and 'Sleep functions' (16.9%). The dominating ICD-10 diagnostic groups were 'Mental and behavioural disorders' (34.4%) and 'Diseases of the musculoskeletal system and connective tissue' (32.8%). 'Reaction to severe stress and adjustment disorders' (14.7%), and 'Depressive episode' (11.5%) were the most frequent diagnostic codes. Disabilities in mental functions and activity/participation were more commonly described among women, while disabilities related to the musculoskeletal system were more frequent among men.
Conclusions
Both ICD-10 diagnoses and ICF categories were dominated by mental and musculoskeletal health problems, but there seems to be gender differences, and ICF classification as a complement to ICD-10 could provide a better understanding of the consequences of diseases and how individual patients can cope with their health problems. ICF is feasible for secondary classifying of free text descriptions of disabilities stated in sick-leave certificates and seems to be useful as a complement to ICD-10 for sick-listing management and research.
doi:10.1186/1471-2458-11-860
PMCID: PMC3229614  PMID: 22078637
10.  Sickness-certification practice in different clinical settings; a survey of all physicians in a country 
BMC Public Health  2010;10:752.
Background
How physicians handle sickness-certification is essential in the sickness-absence process. Few studies have focused this task of physicians' daily work. Most previous studies have only included general practitioners. However, a previous study indicated that this is a common task also among other physicians. The aim of this study was to gain detailed knowledge about physicians' work with sickness-certification and of the problems they experience in this work.
Methods
A comprehensive questionnaire regarding sickness-certification practice was sent home to all physicians living and working in Sweden (N = 36,898; response rate: 61%). This study included physicians aged <65 years who had sickness-certification consultations at least a few times a year (n = 14,210). Descriptive statistics were calculated and odds ratios (OR) with 95 % confidence intervals (CI) were estimated for having different types of related problems, stratified on clinical settings, using physicians working in internal medicine as reference group.
Results
Sickness-certification consultations were frequent; 67% of all physicians had such, and of those, 83% had that at least once a week. The proportion who had such consultations >5 times a week varied between clinical settings; from 3% in dermatology to 79% in orthopaedics; and was 43% in primary health care. The OR for finding sickness-certification tasks problematic was highest among the physicians working in primary health care (OR 3.3; CI 2.9-3.7) and rheumatology clinics (OR 2.6; CI 1.9-3.5). About 60% found it problematic to assess patients' work capacity and to provide a prognosis regarding the duration of work incapacity.
Conclusions
So far, most interventions regarding physicians' sickness-certification practices have been targeted towards primary health care and general practitioners. Our results indicate that the ORs for finding these tasks problematic were highest in primary health care. Nevertheless, physicians in some other clinical settings more often have such consultations and many of them also find these tasks problematic, e.g. in rheumatology, neurology, psychiatry, and orthopaedic clinics. Thus, the results indicate that much can be gained through focusing on physicians in other types of clinics as well, when planning interventions to improve sickness-certification practice.
doi:10.1186/1471-2458-10-752
PMCID: PMC3016384  PMID: 21129227
12.  Dealing with sickness certification – a survey of problems and strategies among general practitioners and orthopaedic surgeons 
BMC Public Health  2007;7:273.
Background
In order to get sickness benefit a sick-listed person need a medical certificate issued by a physician; in Sweden after one week of self-certification. Physicians experience sick-listing tasks as problematic and conflicts may arise when patients regard themselves unable to work due to complaints that are hard to objectively verify for the physician. Most GPs and orthopaedic surgeons (OS) deal regularly with sick-listing issues in their daily practice. The aim of this study was to explore perceived problems and coping strategies related to tasks of sickness certification among general practitioners (GP) and orthopaedic surgeons (OS).
Methods
A cross-sectional study about sickness certification in two Swedish counties, with 673 participating GPs and 149 OSs, who answered a comprehensive questionnaire. Frequencies together with crude and adjusted (gender and working years) Odds ratios were calculated.
Results
A majority of the GPs and OSs experienced problems in sickness certification every week. To assess the patient's work ability, to handle situations when they and the patient had different opinions about the need for sickness absence, and to issue prolongation certificates when the previous was issued by another physician were reported as problematic by a majority in both groups. Both GPs and OSs prolonged sickness certifications due to waiting times in health care or at Social Insurance Office (SIO). To handle experienced problems they used different strategies; OSs issued sickness certificates without personal appointment more often than the GPs, who on the other hand reported having contact with SIO more often than the OSs. A higher rate of GPs experienced support from management and had a common strategy for handling sickness certification at the clinic than the OSs.
Conclusion
Most GPs and OSs handled sickness certification weekly and reported a variety of problems in relation to this task, generally GPs to a higher extent, and they used different coping strategies to handle the problems.
doi:10.1186/1471-2458-7-273
PMCID: PMC2089078  PMID: 17910746
13.  Frequency and nature of problems associated with sickness certification tasks: A cross-sectional questionnaire study of 5455 physicians 
Objective
To study the frequency and nature of problems associated with physicians’ sickness certification practices.
Design
Cross-sectional questionnaire study.
Setting
Stockholm and Östergötland Counties in Sweden.
Subjects
Physicians aged ≤64 years, n =7665, response rate 71% (n =5455).
Main outcome measures
The frequency of consultations involving sickness certification, the frequency and nature of problems related to sickness certification.
Results
A total of 74% (n =4019) of the respondents had consultations including sickness certification at least a few times a year. About half of these physicians had sickness certification cases at least six times a week, and 1 out of 10 (9.4%) had this more than 20 times a week. The items that the highest percentage of physicians rated as very or fairly problematic included: handling conflicts with patients over certification, assessing work ability, estimating optimal length and degree of absence, and managing prolongation of sick leave initially certified by another physician. There were large differences in frequency and nature of problems between different types of clinics/practices. General practitioners had the highest frequency of problems concerning sickness certification while the lowest was found among specialists in internal medicine and surgery.
Conclusion
Sickness certification should be recognized as an important task also for physicians other than general practitioners. The physicians experienced problems with numerous tasks related to sickness certification and these varied considerably between types of clinics. The high rate of problems experienced may have consequences for the physicians’ work situation, for patients, and for society.
doi:10.1080/02813430701430854
PMCID: PMC3379778  PMID: 17846937
Family practice; healthcare; insurance medicine; physicians; sickness certification; sick leave

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