Quality of sickness certification in primary health care: a retrospective database study

Sickness certificates issued by physicians are mandatory after one week of self-certification, when a person applies for benefits due to sickness in Sweden. All physicians in Sweden are obliged to issue these certificates. Most of them are issued in general practice [1].

Between 2004 and 2009, there were national and regional initiatives in place to help health care providers handle their responsibility for issuing sickness certificates (Table 1). Furthermore, there has been much focus on the quality of the certificates issued by physicians. The Swedish government has carried out a set of legislative changes in the social security system, such as the introduction of time limited certificates in July 2008. National clinical guidelines with recommended times for sickness certification for different diagnoses were introduced in 2007 to facilitate and standardise physicians’ assessments [2]. Together with educational initiatives tailored for physicians, the measures are expected to reduce the number of individuals on sick leave.

A report by the Swedish Social Insurance Administration found there was an urgent need to focus on the content of sickness certificates, as they often contain insufficient information [3‐6]. National initiatives have been directed towards general practice where the majority of sickness certificates are issued. Differences in the quality of sickness certificates due to context and patient mix have previously been identified [7, 8].

The management of a clinic or a primary health care centre (PHCC) is responsible for the quality of the sickness certificates issued by the physicians they employ. To ensure a high quality of sickness certificates, regular monitoring of the sickness certification practices of physicians are necessary.

Since 2004, a group of 27 PHCCs in Stockholm County has been working on bench marking, contributing data and getting feedback regarding various clinical diagnoses and treatments, including sickness certification (the “EK-group”, Efterutbildning och Kvalitet, standing for education and quality). A few of the PHCCs in the network, constituting a “quality group”, have worked on a research project that focuses on the quality of sickness certificates. Between 2008 and 2009, this quality group participated in a joint action with PHCCs from four other Swedish counties to investigate certain quality parameters such as adherence to recommendations on sickness certification from the Regional Social Insurance Medicine Committee of the Stockholm County Council; the sickness certificate forms themselves; knowledge about quality in sickness certification; and the possibility of retrieving data from sickness certificates contained in electronic patient records (EPR). At the beginning the quality control group suggested 18 parameters, which were subsequently tested in a pilot study [9]. Of those 18 parameters, seven were thought to be suitable for highlighting quality aspects in a relevant and measurable way, and were therefore chosen for additional tests. The main selection criteria were face validity, simplicity, and the possibility to determine target levels. Preliminary target levels were also determined for these parameters (except for the parameter “number of days on the first sickness certificate”).

In the current study we observed an increase in the quality of sickness certification between 2004 and 2009 in primary health care in Stockholm County by means of examining all sickness certificates issued during that period. Time was the decisive factor, and accounted for the variability observed in three of the seven parameters assessed, i.e. number of days on the first certificate, completely filled in certificates and acceptable certificates, and to some extent for one of the parameters, namely face-to-face consultations.

There are few studies that have examined the parameters in the current study, and no other study has measured changes in sickness certification over time. Information about the need for vocational rehabilitation after 30 days of absence was lacking in 60% of the certificates in a Swedish study of general practitioners’ certificates from 2002 [3]. With regard to information about prognosis for return to work after 30 days of absence, two Swedish studies [3, 10] showed that it was lacking in 29% and 27% of the certificates, respectively. These results were consistent with our findings from 2004. Notes on medical history, physical examination and functional limitations in the sickness certificates comprised a compound measure in the current study and may therefore be difficult to compare to findings from previous studies. Nevertheless, in an earlier Swedish study, information about physical examination was missing in 35% of certificates, and 52% of these contained unclear information about functional capacity, which is similar to our results [3].

The reduction in the number of days on the first sickness certificate that was observed in this study over time was paralleled by a decrease in the total number of sickness days in the population during the same period. The median number of days of fulltime sickness absence per 10 000 inhabitants attending the 21 PHCC was 31 830 in 2004 and 19 769 in 2009 (data presented in a report in Swedish) [11]. The rise in the proportion of face-to-face consultations over time may have been influenced by financial changes that affected PHCCs in 2007 when funds to conduct telephone consultations were withdrawn.

The main strength of this study was its use of authentic data retrieved directly from the medical records in 21 PHCCs of Stockholm County covering six consecutive years, and the large sample population, consisting of more than 200 000 sickness certificates. Although a number of factors were shown to affect sickness certification, we cannot exclude the possibility that other explanatory factors may have been involved which were not studied here.

Since 2008, time limits have been used in the Swedish social security system. This has made parameters 4–7 more important than ever before. Information about the need for vocational rehabilitation and prognosis for return to work (parameters 4 and 5) is necessary for the implementation of measures taken by the employer and the social insurance officer to support persons on sick leave who wish to return to work. Complete and detailed information (parameter 6) is required by the Social Insurance Offices after 30 days of sickness absence, while a minimum amount of information (parameter 7) is needed in all cases. Overall, better planning is required to avoid long, drawn-out benefit payments. We found a considerable discrepancy between preliminary target quality levels and actual quality levels in relation to information about the need for vocational rehabilitation and complete certificates. This discrepancy implies that additional efforts would be needed to improve the quality of those two parameters.

The fact that the PHCCs in the quality network did not get better results than the others may indicate that getting feedback on sickness certification is not enough to improve sickness certification; local quality work is needed as well. Overall, GPs in many countries regard sickness certification as a complex task [12‐14].

Educational initiatives have been, by far, the most commonly used way to bring about change in physicians’ sickness certification practices, but their effect on the quality of certificates issued was found to have been rather small, perhaps due to insufficient or inadequate focus [15]. Complementary measures would be required to change physicians’ sickness certification practices. One such measure could be the use of reminders, which has been shown to be successful, for example, in safe drug prescriptions [16]. Another tool might be electronic completion and on-line transmission of the sickness certificate, which is introduced in other parts of Sweden as well as in Italy [17]. Using this method, filling in certain fields could be made compulsory, which would automatically affect parameters 4–7 in this study.

A parameter not addressed in this study but which may have affected quality of sickness certificates is problems physicians may have in making the necessary assessments. This has been demonstrated in earlier Swedish studies as well in studies from other countries [12, 14, 18]. To resolve this, the WHO International Classification of Functioning Disability and Health (ICF) has been discussed as a possible tool. In Sweden, measures have been taken to use ICF codes in a structured way that is integrated into the electronic sickness certificate system. A pilot study of ours conducted in Stockholm County implied that the use of ICF, via ICF Core Sets, could be a way to increase the quality of the descriptions of activity limitations, an area where improvements are urgently needed (submitted).

The quality of the sickness certification practice improved over time during the study period with respect to the number of days on first certification and the proportion of properly completed and acceptable certificates but assessment of the need for vocational rehabilitation and giving a prognosis for return to work were not significantly improved over time during the same period. Although the quality levels of all these parameters were not satisfactory they may provide a good basis for further work. To improve the quality of sickness certificates, measures, such as reminders, compulsory certificate fields, and structured guidance, would be needed.

YS has many years of experience as a specialist in General Practice, and has a PhD including studies on Medical Judgement and Decision-making. She holds a position as Associated Professor at Karolinska Institutet, Stockholm, Sweden.

BA has many years of experience as a specialist in General Practice, and has a PhD that included studies on sickness certification. She holds a position as Senior Consultant and Medical expert in Social Insurance Medicine, Stockholm County Council, Sweden.

LGB has many years of experience as a specialist in General Practice. He has a PhD that included studies on Medical Judgement and Decision-making and holds a position as a researcher at Karolinska Institutet, Stockholm, Sweden.

MF is a specialist in General Practice. She has developed a web–based tool for using ICF as a tool in the sickness certification process.

AWÅ is a statistician and has been working for many years with large data bases in Stockholm County Council, Sweden.

GHN is a specialist in General Practice, and has a PhD that included studies in informatics and decision-making. He holds a position as professor at Karolinska Institutet, Stockholm, Sweden.

All authors are members of a research group at the Centre for Family Medicine, Karolinska Institutet that works with and plans a number of studies related to the quality of sickness certification.