Family Practice Vol. 17, No. 2, 139-144
© Oxford University Press 2000
Work ability assessed by patients and their GPs in new episodes of sickness certification
a Institute of General Practice and Community Medicine, Department of Social Insurance Medicine, University of Oslo, PO Box 1130 Blindern, N-0318 Oslo and
b Aust-Agder County Office of the National Insurance Service, PO Box 188, N-4802 Arendal, Norway.
Reiso H, Nygård JF, Brage S, Gulbrandsen P and Tellnes G. Work ability assessed by patients and their GPs in new episodes of sickness certification. Family Practice 2000; 17: 139–144.
Received 23 April 1999; Revised 9 September 1999; Accepted 26 October 1999.
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Abstract |
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 Top Abstract IntroductionMaterials and methodsResultsDiscussionReferences |
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Background. Sickness certification legislation demands that work ability is reduced due to disease or injury. Most sickness certificates are issued by GPs. Assessment of work ability might introduce conflict in the doctor–patient relationship.
Objectives. The aim of this study was to compare the level of work ability assessments by patients and their GPs in new episodes of sickness certification, and to explore how medical conditions and work demands are associated with the assessments.
Methods. Forty nine GPs supplied data about 408 patients certified sick <8 days before questionnaires were filled in. A total of 268 (66%) patients completed corresponding questionnaires. Patients and GPs independently answered the following question using a five-point scale: "To what degree is your (the patient's) ability to perform your (his or her) ordinary, remunerative work reduced today?"
Results. Work ability was assessed by patients as very much or much reduced in 66%, moderately reduced in 23% and not much or hardly reduced at all in 11% of the cases. Corresponding assessments made by GPs were 71, 27 and 2%. Patients and GPs agreed well on their assessments (± 1 answer category) in 81% (216/266) of the cases. The patients assessed work ability as more reduced the more stressful or physically strenuous their jobs were, and the older their GPs were. The GPs assessed work ability as more reduced the more their assessments were based on clinical findings.
Conclusions. The agreement between work ability assessments made by patients and GPs was high, despite patients' assessments being associated with work demands and GPs' with medical conditions.
Keywords. Functional assessment, sickness absence, sickness certification, sick-listing, work ability.
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Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Sickness benefit payments account for >10% of the social insurance costs in Norway. Persons receiving sickness benefits must be ". . . incapacitated for work due to a loss of function that clearly is caused by disease or injury", according to Norwegian legislation. Similar criteria are used in Sweden and the UK, where "reduced work ability" and "incapable of work" are phrases used to describe reduced work capacity.1
Doctors have difficult and conflicting roles as assessors of function in social insurance medicine. Their dilemmas concern assessment of work incapacity, duration of sick leave, interpreting sickness benefit legislation and giving social interpretations to medical diagnoses.2 Should doctors act as gatekeepers for social insurance benefits, or serve as advocates for their patients when assessing work ability? The roles conflict, and the former may introduce strain in the doctor–patient relationship. This particularly concerns GPs, because they issue >80% of sickness certificates in Norway.3
Whether sickness certification will be a consequence of reduced work ability depends on the medical conditions and work demands of the patients.4,5 There is scarce knowledge about how these factors are associated with each other.2,6,7
In order to measure function, indicators such as self-reported function,8–11 assessments made by observers11 or more specific physiological tests can be used. However, most of these methods consist of several items, they are time consuming and are therefore unsuitable for everyday clinical practice. We were not aware of any tool designed for assessment of work ability in early periods of sickness certification in general practice, and therefore we developed a simple questionnaire for that purpose.
The present study is aimed at exploring the level of work ability assessed by patients and their GPs in new episodes of sickness certification, the degree to which these assessments coincided or conflicted, and whether they were associated with medical conditions or work demands.
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Materials and methods |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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A pilot study was conducted in 1994. Five meetings with GPs and social insurance officers were held prior to it, in order to ensure the relevance of the questionnaires. No difficulties were reported in completing 116 questionnaires by 16 GPs and their patients. There was a good spread in the use of answer categories and there were few missing data.
Work ability in sickness certification was defined as the physical and psychological capacity of a person to perform ordinary, remunerative work.
The study was conducted in January–April 1996, in the county of Aust-Agder, southern Norway. The county had 100 211 inhabitants as per January 1, 1996. The number of persons with sickness benefit rights, aged 16–66 years, was 47 835 in 1996.
All GPs (85) in the county were invited to participate in the study. Each doctor could record 25 consecutive sickness certification episodes in ordinary daytime practice. All types of contacts were eligible. Questionnaires were given to the patients by their GPs, together with a post-paid envelope addressed to us. The GPs were thus blinded to the patients' responses. The study had a two-stage design,12 as the selection of GPs represented the first stage of data collection and the consultations between GPs and patients the second. Patients and GPs were assured that participation in the study would not affect the certificates. For episodes registered more than once, only the first record was included in the analysis.
Variables
Patients and GPs answered the following question about work ability using a five-point scale: "To what degree is your (the patient's) ability to perform your (his or her) ordinary, remunerative work reduced today?" The question was developed from a Graded Reduced Work Ability scale, constructed for the Norwegian Ministry of Health and Social Affairs.10
The GPs classified the main sick-listing diagnoses according to ICPC (International Classification of Primary Care), recorded the kind of clinical information sources that they used when assessing work ability, and their use of clinical examinations or tests in the consultations. Doctors and patients also evaluated whether non-medical factors could have influenced their work ability assessments.
The patients gave information about their occupations and work demands. The latter was operationalized as the number of remunerative working hours per week, daytime or night/shift work, a subjective description of physical work demands, heavy lifting, self-determined breaks, conflicts, stressful working conditions, satisfaction and influence in their jobs.
The GPs provided information about their own age and gender and the patients' age and gender.
Statistical analyses
Continuous variables were compared using two-tailed t-tests, categorized by chi-square statistics. Diagnoses were recoded into diagnostic groups.
Design-based analyses were performed using STATA® software,12 with GPs as the primary sampling units. Design-based multiple logistic regression analyses included variables with univariate P-values <0.20 when compared with work ability, and age and gender of patients and GPs. Assessed work ability was recoded into very much/much reduced, and moderately/not much/ hardly reduced at all in these analyses. Intercorrelation between independent variables was checked by Spearman's rank correlation coefficient.
The chosen level of significance was 5%.
The sample
A total of 1001 questionnaires from GPs were collected. 138 questionnaires were excluded due to double recordings (57 cases), uncertain certification dates (30), patients certified sick while on rehabilitation benefits (28), unconfirmed patient identities (10) or other reasons (13).
Since assessments of work ability when issuing new sickness certificates, or prolonging them, represent different clinical problems, this study concerns new certificates only. Patients had been certified sick <8 days before the completion of questionnaires in 408 cases. These were defined as new episodes of sickness certification. The patient response rate was 66% (268/408).
Fifty-eight percent (49/85) of the invited GPs participated. The number of patients recorded for each doctor varied between four and 15. The age range of the doctors was 28–78 years (mean 44 years) and 27% (13/49) were women, which was not significantly different from non-participating doctors.
The age range of patient respondents was 18–64 years; 57% were women. Respondents were older than non-respondents, mean 40 years versus 36 years (P < 0.05). Gender and diagnoses were not significantly different between respondents and non-respondents.
Spearman's rank correlation coefficients were <0.50 in all the independent variables that were eligible for the logistic regression analyses.
The representativeness of the study was checked by comparison with the National Sickness Benefit Register. Participating doctors had more female sick-listed patients than non-participating doctors, 57% versus 44% (P < 0.05). Age and diagnoses of patients in this study and of other patients of participating doctors recorded in the register were not significantly different, nor were age and diagnoses of patients of participating and non-participating doctors recorded in the register.
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Results |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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The patients assessed work ability as very much or much reduced in 66%, moderately reduced in 23%, and not much or hardly reduced at all in 11% of the cases (Table 1
). The corresponding assessments made by the GPs were 71, 27 and 2%.
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Patients and GPs agreed in 40% (107/266) of their assessments, and had good agreement (± 1 answer cat-egory) in 81% (216/266) of the cases. Good agreement ranged from 64% (16/25) in upper respiratory infections to 100% in depression (16/16). Work ability was assessed as more reduced by patients than by GPs in 75 cases, by more than one answer category in 15 cases, while corresponding figures, where GPs assessed work ability as more reduced than patients, were 84 and 35 (Table 1
).
Patients assessed work ability as more reduced the more stressful their jobs were, and the older their GPs were (Table 2).
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Patients had a tendency to assess work ability as more reduced when their jobs were physically strenuous. Work ability was assessed by the patients as significantly more reduced for sinusitis and back disorders than for all other disorders. The patient assessments were not significantly associated with their own age or gender, nor with the gender of the GPs.
The GPs assessed work ability as more reduced the more their assessments were based on clinical findings, and less reduced when influenced by non-medical factors (Table 3).
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The information sources of the GPs for assessing work ability were based mainly on statements by the patients in 66%, and on clinical findings in 34%. They assessed work ability as significantly more reduced for depression than for all other disorders. The GPs' work ability assessments were not significantly associated with their own age or gender, or the age or gender of the patients.
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Discussion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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The pilot study did not forward discussions concerning interpretations of the questionnaire. We assumed that the question about work ability had good face validity. Others have found an internal consistency of 0.71 (Cronbach's alpha) concerning patient answers to the Graded Reduced Work Ability scale questions.10 Patients in this study and in the National Sickness Benefit Register were similar with respect to age, gender and diagnoses. We found a distribution of diagnostic groups as in other studies.3,6 The reliability of diagnoses on sickness certificates is good; intra- and inter-observer concordance for diagnostic groups is 97 and 91%, respectively.3 In a Swedish study, coding from medical certificates to registers was correct in 98%, while diagnoses based on texts in medical records matched diagnostic groups in 72%.13
Categorizations and assessments presumably were influenced by the attitudes and experiences of the doctor. Intra-doctor correlation between the questionnaires is therefore likely. Design-based analyses takes this into account, as opposed to ‘model-based’ analyses.12
Work ability and work demands of persons not sick-listed were not recorded in the present study, which should be considered when interpreting the results.
Most assessments by doctors and patients were very much or much reduced work ability. This should be expected, because the study sample concerned sick-listed patients only.
GPs assessed work ability as more reduced than the patients did, but there were only a few conflicting assessments. This is in contrast to a study that compared patients' and social insurance medicine doctors' assessments of function after 26 weeks of disability benefits,11 in which patients assessed work ability as more reduced than the doctors did. That study also found lower doctor–patient agreement than we did. This might be a reflection of the different clinical situations between issuing a new certificate or prolonging one.
Good agreement in work ability assessments by patients and GPs could be the result of negotiations that take place in consultations concerning sickness certification.6,14 Psychosocial problems seem to be more common among work-disabled than non-work-disabled patients.15 GPs are good at identifying their patients' work-related problems,16 and patients' self-perceived work disability is the socio-economic factor that GPs are best at evaluating.17 Doctors frequently have to deal with such problems, as a gatekeeper of social insurance benefits. Work-related problems might be easier to handle than more serious psychosocial problems, and issuing sickness certificates can represent ‘silent agreement’ solutions to unrevealed problems.
Work ability assessed by patients was associated with stress. The distribution of physical work demands in our study was similar to findings in other studies.14 Work ability assessed by GPs was not associated with the work demands of the patients. As there were few conflicting work ability assessments by GPs and patients, increasing the GPs' knowledge about the work demands of their patients will not really reduce such conflict.
Why was work ability assessed by patients associated with the age of their GPs? Perhaps older doctors convey more empathy and trust than younger doctors, making it easier for patients to assess their work ability as more reduced. Is such a ‘Grandpa effect’ the explanation, or could it be that older doctors have lost their power of resistance concerning requests from patients about sickness certificates, so that patients in need of sick leave seek older doctors? One case history inquiry on sickness certification might support the latter selection hypothesis, because younger doctors generally were more restrictive towards sick-listing than their older colleagues.18
Work ability was assessed as most reduced in sinusitis and back disorders by patients, and in depression by GPs. These diagnostic groups are large and important in sickness certification.3,19 Back disorders and depression become increasingly important the longer the duration of the certification episodes.20 Can self-assessed work ability by patients with back pain be a good measure of function compared with other more objective methods? Self-evaluated work ability correlates well with clinically determined musculoskeletal capacity in healthy women, and in women with back disorders.21
Work ability assessed by GPs was associated with clinical findings, as in other studies.7 However, in a study of low back pain, the proportion of patients without objective findings increased with the duration of sickness absence.22
The GPs seemed to focus first on medical conditions, then on the functional consequences for work ability, as doctors are supposed to do according to sickness benefit legislation.
Conclusions
The agreement between work ability assessments made by patients and GPs was high, despite patients' assessments being associated with work demands and GPs' with medical conditions.
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Acknowledgments |
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The study was approved by the Regional Ethics Committee for Medical Research, the Norwegian Data Inspectorate and the Legal Affairs Division in the National Insurance Administration. It was supported by the Norwegian Ministry of Health and Social Affairs, Aust-Agder County Office of the National Insurance Services, the National Insurance Administration and the University of Oslo.
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References |
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1 Bonner D, Hooker I, White R. Non Means Tested Benefits: The Legislation, Statutory Sick Pay (General) Regulations. London: Sweet and Maxwell, 1998.
2
Timpka T, Hensing G, Alexanderson K. Dilemmas in sickness certification among Swedish physicians. Eur J Public Health 1995; 5: 215–219.
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5 Karasek R, Theorell T. Healthy Work: Stress, Productivity and the Reconstruction of Working Life. New York: Basic Books, 1990: 31–44.
6
Tellnes G. Sickness certification in general practice: a review. Fam Pract 1989; 6: 58–65.
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8 Bentsen BG, Natvig B, Winnem M. Assessment of own functional status. COOP-WONCA charts in clinical work and research. Tidsskr Nor Lægeforen 1997; 117: 1790–1793 (in Norwegian, English summary).
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12
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Gulbrandsen P, Hjortdahl P, Fugelli P. General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey. Br Med J 1997; 314: 1014–1018.
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20 Brage S, Nygård JF, Tellnes GT. Long-term Sickness Certification in Norway 1989–94. Report 98:3. Oslo: Department of Social Insurance Medicine, University of Oslo, 1998 (in Norwegian).
21 Eskelinen L, Kohvakka A, Merisalo T, Hurri H, Wägar G. Relationship between the self-assessment and clinical assessment of health status and work ability. Scand J Work Environ Health 1991; 17 (Suppl 1): 40–47.
22 Vällfors B. Acute, subacute and chronic low back pain: clinical symptoms, absenteeism and working environment. Scand J Rehab Med 1985; 17 (Suppl 11): 1–98.[Web of Science][Medline]
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