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1.  Quality of sickness certification in primary health care: a retrospective database study 
BMC Family Practice  2013;14:48.
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.
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.
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.
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.
PMCID: PMC3637144  PMID: 23586694
General practitioners; Sick leave; Sickness certificates; Quality indicators; Health care
2.  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.
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.
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.
Primary healthcare in all Sweden.
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.
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.
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.
PMCID: PMC3244659  PMID: 22189350
3.  Frequency and severity of problems that general practitioners experience regarding sickness certification 
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.
A cross-sectional national questionnaire study. Setting. Primary health care in Sweden.
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%.
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.
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.
PMCID: PMC3308465  PMID: 22126222
GP; physicians; primary health care; sickness certification; sick leave
4.  Sickness-certification practice in different clinical settings; a survey of all physicians in a country 
BMC Public Health  2010;10:752.
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.
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.
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.
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.
PMCID: PMC3016384  PMID: 21129227
5.  Primary Prevention of First-Ever Stroke in Primary Health Care: A Clinical Practice Study Based on Medical Register Data in Sweden 
Stroke Research and Treatment  2010;2010:468412.
Background. The aim of this study was to investigate whether established risk factors for stroke in patients admitted to health care for first-ever stroke had been detected and treated in primary health care. Methods. In a retrospective study in Nacka municipality, Stockholm County, Sweden, with about 70 000 inhabitants, we included all men and women admitted to health care due to first-ever stroke between October 1999 and March 2001. Data on 187 such patients, with a mean age of 75 years, were obtained from medical registers. Main outcome measures were detection and treatment of risk factors for stroke including hypertension, diabetes, atrial fibrillation, smoking, alcohol abuse, and overweight/obesity. Results. In a majority of patients seen in primary health care with hypertension and diabetes, those risk factors were detected and treated (75.6% and 75.0%, resp.). Fewer patients with atrial fibrillation received treatment (60.9%). Treatment of lifestyle factors was difficult to assess because of lack of data in the medical records. Conclusions. Primary prevention of stroke in primary health care needs to be improved, especially when atrial fibrillation and lifestyle-related risk factors are present. Health policies need to target not only the public, but also general practitioners and other health care professionals.
PMCID: PMC2915654  PMID: 20721332
6.  Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study 
BMC Family Practice  2010;11:47.
Survivers of stroke or transient ischaemic attacks (TIA) are at risk of new vascular events. Our objective was to study primary health care patients with stroke/TIA regarding their knowledge about risk factors for having a new event of stroke/TIA, possible associations between patient characteristics and patients' knowledge about risk factors, and patients' knowledge about their preventive treatment for stroke/TIA.
A questionnaire was distributed to 240 patients with stroke/TIA diagnoses, and 182 patients (76%) responded. We asked 13 questions about diseases/conditions and lifestyle factors known to be risk factors and four questions regarding other diseases/conditions ("distractors"). The patients were also asked whether they considered each disease/condition to be one of their own. Additional questions concerned the patients' social and functional status and their drug use. The t-test was used for continuous variables, chi-square test for categorical variables, and a regression model with variables influencing patient knowledge was created.
Hypertension, hyperlipidemia and smoking were identified as risk factors by nearly 90% of patients, and atrial fibrillation and diabetes by less than 50%. Few patients considered the distractors as stroke/TIA risk factors (3-6%). Patients with a family history of cardiovascular disease, and patients diagnosed with carotid stenosis, atrial fibrillation or diabetes, knew these were stroke/TIA risk factors to a greater extent than patients without these conditions. Atrial fibrillation or a family history of cardiovascular disease was associated with better knowledge about risk factors, and higher age, cerebral haemorrhage and living alone with poorer knowledge. Only 56% of those taking anticoagulant drugs considered this as intended for prevention, while 48% of those taking platelet aggregation inhibitors thought this was for prevention.
Knowledge about hypertension, hyperlipidemia and smoking as risk factors was good, and patients who suffered from atrial fibrillation or carotid stenosis seemed to be well informed about these conditions as risk factors. However, the knowledge level was low regarding diabetes as a risk factor and regarding the use of anticoagulants and platelet aggregation inhibitors for stroke/TIA prevention. Better teaching strategies for stroke/TIA patients should be developed, with special attention focused on diabetic patients.
PMCID: PMC2894756  PMID: 20550690
7.  Self-rated health, symptoms of depression and general symptoms at 3 and 12 months after a first-ever stroke: a municipality-based study in Sweden 
BMC Family Practice  2007;8:61.
Self-rated health is an important indicator of quality of life as well as a good predictor of future health. The purpose of the study was to follow up the self-rated health and the prevalence of symptoms of depression and general symptoms in a population of first-ever stroke patients 3 and 12 months after stroke.
All patients surviving their first-ever stroke and residing in Nacka municipality in Stockholm County Council were included using a multiple overlapping search strategy during an 18-month period (n = 187). Our study group comprised the 145 patients who survived the first 3 months after stroke. Three and 12 months after their stroke, the patients were assessed regarding self-rated health and general symptoms using parts of the Göteborg Quality of Life Instrument (GQLI), and regarding symptoms of depression using the Montgomery Asberg Depression Scale (MADRS-S).
Self-rated health was rated as very good or rather good by 62% at 3 months after stroke and by 78% at 12 months after stroke. More than half of the patients suffered from symptoms of depression, with no significant improvement at 12 months. The most common general symptoms at 3 months after stroke were fatigue, sadness, pain in the legs, dizziness and irritability. Fatigue and sadness were still common at 12 months. Twelve months after stroke the prevalences of crying easily, irritability, impaired concentration, nausea and loss of weight were significantly lower.
The majority of patients rated their health as rather good or very good at 3 and 12 months after stroke. However, the majority suffered from fatigue and from symptoms of depression after both 3 and 12 months. In continued care of stroke survivors, it is important to consider the fact that many patients who rate their health as good may nevertheless have symptoms of depression, and some of them may benefit from anti-depressive treatment.
PMCID: PMC2174472  PMID: 17941995
8.  Mapping the categories of the Swedish primary health care version of ICD-10 to SNOMED CT concepts: Rule development and intercoder reliability in a mapping trial 
Terminologies and classifications are used for different purposes and have different structures and content. Linking or mapping terminologies and classifications has been pointed out as a possible way to achieve various aims as well as to attain additional advantages in describing and documenting health care data.
The objectives of this study were:
• to explore and develop rules to be used in a mapping process
• to evaluate intercoder reliability and the assessed degree of concordance when the 'Swedish primary health care version of the International Classification of Diseases version 10' (ICD-10) is matched to the Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT)
• to describe characteristics in the coding systems that are related to obstacles to high quality mapping.
Mapping (interpretation, matching, assessment and rule development) was done by two coders. The Swedish primary health care version of ICD-10 with 972 codes was randomly divided into an allotment of three sets of categories, used in three mapping sequences, A, B and C. Mapping was done independently by the coders and new rules were developed between the sequences. Intercoder reliability was measured by comparing the results after each set. The extent of matching was assessed as either 'partly' or 'completely concordant'
General principles for mapping were outlined before the first sequence, A. New mapping rules had significant impact on the results between sequences A - B (p < 0.01) and A - C (p < 0.001). The intercoder reliability in our study reached 83%. Obstacles to high quality mapping were mainly a lack of agreement by the coders due to structural and content factors in SNOMED CT and in the current ICD-10 version. The predominant reasons for this were difficulties in interpreting the meaning of the categories in the current ICD-10 version, and the presence of many related concepts in SNOMED CT.
Mapping from ICD-10-categories to SNOMED CT needs clear and extensive rules. It is possible to reach high intercoder reliability in mapping from ICD-10-categories to SNOMED CT. However, several obstacles to high quality mapping remain due to structure and content characteristics in both coding systems.
PMCID: PMC1876209  PMID: 17472757
9.  General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study 
Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines.
Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines.
Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument.
The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way.
PMCID: PMC546006  PMID: 15651996
10.  GPs' decisions on drug treatment for patients with high cholesterol values: A think-aloud study 
The purpose was to examine how General Practitioners (GPs) use clinical information and rules from guidelines in their decisions on drug treatment for high cholesterol values.
Twenty GPs were presented with six case vignettes and were instructed to think aloud while successively more information about a case was presented, and finally to decide if a drug should be prescribed or not. The statements were coded for the clinical information to which they referred and for favouring or not favouring prescription.
The evaluation of clinical information was compatible with decision-making as a search for reasons or arguments. Lifestyle-related information like smoking and overweight seemed to be evaluated from different perspectives. A patient's smoking favoured treatment for some GPs and disfavoured treatment for others.
The method promised to be useful for understanding why doctors differ in their decisions on the same patient descriptions and why rules from the guidelines are not followed strictly.
PMCID: PMC539306  PMID: 15596005
11.  The role of guidelines and the patient's life-style in GPs' management of hypercholesterolaemia 
Recent Swedish and joint European guidelines on hyperlipidaemia stress the high coronary risk for patients with already established arterio-sclerotic disease (secondary prevention) or diabetes. For the remaining group, calculation of the ten-year risk for coronary events using the Framingham equation is suggested. There is evidence that use of and adherence to guidelines is incomplete and that tools for risk estimations are seldom used. Intuitive risk estimates are difficult and systematically biased. The purpose of the study was to examine how GPs use knowledge of guidelines in their decisions to recommend or not recommend a cholesterol-lowering drug and the reasons for their decisions.
Twenty GPs were exposed to six case vignettes presented on a computer. In the course of six screens, successively more information was added to the case. The doctors were instructed to think aloud while processing the cases (Think-Aloud Protocols) and finally to decide for or against drug treatment. After the six cases they were asked to describe how they usually reason when they meet patients with high cholesterol values (Free-Report Protocols). The two sets of protocols were coded for cause-effect relations that were supposed to reflect the doctors' knowledge of guidelines. The Think-Aloud Protocols were also searched for reasons for the decisions to prescribe or not to prescribe.
According to the protocols, the GPs were well aware of the importance of previous coronary heart disease and diabetes in their decisions. On the other hand, only a few doctors mentioned other arterio-sclerotic diseases like stroke and peripheral artery disease as variables affecting their decisions. There were several instances when the doctors' decisions apparently deviated from their knowledge of the guidelines. The arguments for the decisions in these cases often concerned aspects of the patient's life-style like smoking or overweight- either as risk-increasing factors or as alternative strategies for intervention.
Coding verbal protocols for knowledge and for decision arguments seems to be a valuable tool for increasing our understanding of how guidelines are used in the on treatment of hypercholesterolaemia. By analysing arguments for treatment decisions it was often possible to understand why departures from the guidelines were made. While the need for decision support is obvious, the current guidelines may be too simple in some respects.
PMCID: PMC394323  PMID: 15113452
12.  Heart failure diagnosis in primary health care: clinical characteristics of problematic patients. A clinical judgement analysis study 
BMC Family Practice  2003;4:12.
Early detection of chronic heart failure has become increasingly important since the introduction of effective treatment. However, clinical diagnosis of heart failure is known to be difficult, especially in mild cases or early in the course of the disease. The purpose of this study is to analyse how patient characteristics contribute to difficulties in diagnosing systolic heart failure.
Design: A Clinical Judgement Analysis study of 40 case vignettes based on authentic patients, including relevant clinical data except echocardiography. Setting: Primary health care and two cardiology outpatient clinics in Stockholm. Subjects: 70 participants with different types of clinical experience; 27 specialists in general practice, 22 cardiologists, and 21 medical students. Main outcome measures: The assessed probability of heart failure for each case vignette, and the disagreement between the participants. The number of clinical variables (cues) indicative of heart failure in the case vignettes.
The ten case vignettes with the least diverging assessments more often had increased relative cardiac volume and atrial fibrillation. No further specific clinical patterns could be found in subgroups of the case vignettes. The ten case vignettes with the most diverging assessments were those with an intermediate number of clinical variables. The case vignettes with the least diverging assessments more often represented patients with cardiac enlargement and atrial fibrillation.
Diagnosing mild heart failure is difficult, as these patients are not easy to characterise. In our study, a larger number of positive cues resulted in more diagnostic conformity among the participants, and the most important information was cardiac enlargement. The importance of more objective diagnostic methods in diagnosing suspected cases of heart failure should be emphasised.
PMCID: PMC222938  PMID: 14498999

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