Dataset Information

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

ABSTRACT:

Background

General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification.

Methods

Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach.

Results

Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence.

Conclusion

Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

SUBMITTER: Hoff EH

PROVIDER: S-EPMC10860288 | biostudies-literature | 2024 Feb

REPOSITORIES: biostudies-literature

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Publications

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

Hoff Eivor Hovde EH Kraft Kristian B KB Moe Cathrine F CF Nylenna Magne M Østby Kristian A KA Mykletun Arnstein A

BMC public health 20240212 1

<h4>Background</h4>General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification.<h4>Methods</h4>Qualit ...[more]

PMID: 38347474

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Project description:BackgroundDepression is among the most frequent reasons for sick leave, whereas health authorities recommend a rather strict practice, arguing that work is health-promoting. We aimed to explore GPs' attitudes and practices regarding sick leave certification for depressed patients.MethodsA cross-sectional study using the Norwegian Physician Survey (N = 1617, 70% response rate) in 2021. The GPs in the panel (N = 221) responded to questions about sick leave certification and cooperation with employers and the Norwegian Labour and Welfare Administration (Norwegian acronym: Nav) regarding patients with depression. We used crosstabulation with chi square statistics and logistic regression models to assess differences among GPs.ResultsAmong 221 GPs, 62% often/very often perceived patients' questions for sick leave certification as the main reason for encountering. A total of 46% often/very often considered patients' expectations inappropriate, with female GPs more frequently than male GPs (36% vs 56%, p = 0.005) and younger GPs more frequently than their older counterparts (p < 0.001). Although 68% considered sick leave as part of treatment, only 16% often/very often initiated sick leave unless patients raised the question. Sixty-seven percent of GPs reported to often/very often avoid sick listing, if possible, more females than males. GPs who often/very often considered questions for sick leave inappropriate less often considered sick leave as part of treatment (odds ratio (OR): 0.25; 95% CI: 0.13-0.49), and less often report a well-functioning cooperation with Nav (OR:0.37; 95% CI:0.14-0.96). GPs who often/very often considered sick leave as part of treatment more often proposed sick leave for their patients (OR:4.70; 96% CI 1.57-14.01) and reported a less strict approach to sick listing (OR: 40; 95% CI: 0.20-0.79). Ninety-five percent of the GPs rarely/never had direct contact with patients' employers, whereas 92% often/very often asked patients about their dialogue with the workplace. Eighty-eight percent of the GPs often/very often experienced cooperation with NAV as good, and 87% often/very often felt trusted by them.ConclusionsMost GPs reported a strict attitude towards sick leave for depression, whereas one-third had a less strict approach. Different perceptions of the appropriateness of sick listing indicate variations in treatment and access to social security benefits.

Project description:BackgroundFrequent sickness absence-that is, 3 or more episodes of sickness absence in 1 year-is a problem for employers and employees. Many employees who have had frequent sickness absence in a prior year also have frequent sickness absence in subsequent years: 39% in the first follow-up year and 61% within 4 years. Moreover, 19% have long-term sickness absence (≥6 weeks) in the first follow-up year and 50% within 4 years. We developed an electronic health (eHealth) intervention, consisting of fully automated feedback and advice, to use either as a stand-alone tool (eHealth intervention-only) or combined with consultation with an occupational physician (eHealth intervention-occupational physician).ObjectiveThis study aimed to evaluate the effect of the eHealth intervention, with or without additional occupational physician consultation, to reduce sickness absence frequency for employees with frequent sickness absence, versus care as usual (CAU).MethodsThis study was a three-armed randomized controlled trial. Employees with frequent sickness absence received invitational letters, which were distributed by their employers. The primary outcome measure was the number of register-based sickness absence episodes 12 months after completing the baseline questionnaire. Secondary outcome measures were register-based total sickness absence days and self-assessed burnout, engagement, and work ability. In a process evaluation 3 months after baseline, we examined adherence to the intervention and additional actions such as general practitioner and occupational physician visit, communication with the manager, and lifestyle change.ResultsA total of 82 participants were included in the analyses, 21 in the eHealth intervention-only group, 31 in the eHealth intervention-occupational physician group, and 30 in the CAU group. We found no significant difference in sickness absence frequency between the groups at 1-year follow-up. Sickness absence frequency decreased in the eHealth intervention-only group from 3 (interquartile range, IQR 3-4) to 1 episode (IQR 0.3-2.8), in the eHealth intervention-occupational physician group from 4 (IQR 3-5) to 3 episodes (IQR 1-4), and in the CAU group from 3 (IQR 3-4) to 2 episodes (IQR 1-3). For secondary outcomes, we found no significant differences between the intervention groups and the control group. The process evaluation showed that only 3 participants from the eHealth intervention-occupational physician group visited the occupational physician on invitation.ConclusionsAmong employees with frequent sickness absence, we found no effect from the eHealth intervention as a stand-alone tool in reducing sickness absence frequency, nor on total sickness absence days, burnout, engagement, or work ability. This might be due to low adherence to the intervention because of insufficient urgency to act. We cannot draw any conclusion on the effect of the eHealth intervention tool combined with an occupational physician consultation (eHealth intervention-occupational physician), due to very low adherence to the occupational physician consultation. An occupational physician consultation could increase a sense of urgency and lead to more focus and appropriate support. As this was the first effectiveness study among employees with frequent sickness absence, strategies to improve recruitment and adherence in occupational eHealth are included.Trial registrationNetherlands Trial Register NTR4316; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4316 (Archived by WebCite at http://www.webcitation.org/713DHhOFU).

Dataset Information

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

Background

Methods

Results

Conclusion

Publications

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification.

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