Sickness certificates in Sweden: did the new guidelines improve their quality?

Abstract

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

Acting by persuasion— values and rhetoric in medical certificates of work incapacity: A qualitative document analysis

“…They need to cease being an ‘orphaned field’, so that future physicians can be conscious about how they write and to what effects. In a Swedish study,44 introducing new and more specific guidelines for GPs’ functional assessments in long time sick-leave showed a limited effect in the form of increased information, whereas there are no corresponding studies made in Norway. There is, however, no evidence that any single measures to be taken would essentially improve medical certificates.…”

Recommendations to facilitate the ideal fit note: are they achievable in practice?

“…The lack of information provided by GPs on patients’ functional ability has been reported elsewhere. Norwegian GPs have reported on their difficulty in assessing and communicating on function [ 23 , 24 ], and in a study of Swedish sickness certificates, only one-third of GPs reported on patients’ activity limitations despite the introduction of new guidelines and implementation strategies [ 14 , 25 ]. Studies set within workers’ compensation schemes also report on discrepancies between the lack of GPs’ knowledge about their patients’ work and the functional advice they are expected to provide [ 26 , 27 ].…”

“…Key recommendations included increased use of electronic fit notes, changes to the fit note format and content, facilitating communication between stakeholders, completion of fit notes by other healthcare professionals, mandatory training in fit note use, auditing of fit notes, and the revision of existing guidance. These consensus statements have the potential to improve the effectiveness of the fit note in returning employees to work, however, recommendations do not necessarily change practice [ 13 , 14 ]. In addition, free-text comments made by the Delphi panellists suggested that further investigation was needed to explore how easily the recommendations might be implemented; this was the aim of this study.…”

Sickness certificates: what information do they provide about rehabilitation?

“…In this study, the description of functioning was not associated with a prescription of early rehabilitation in comparison with diagnosis, age, and physician type. On the other hand, the description of functioning in sickness certificates needs improvement, including activity limitations or participation restrictions [35].…”