Should General Practitioners Issue a Sick Certific

Authors: M Lewis G WynneJones P Barton D G T Whitehurst S Wathall N E Foster E M Hay D van der Windt

Publish Date: 2015/01/17

Volume: 25, Issue: 3, Pages: 577-588

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Abstract

Purpose Back pain is a common problem and has significant societal impact Sickness certification is commonly issued to patients consulting their general practitioner with low back pain The aim of this study was to investigate the association of certification for low back pain with clinical outcomes and cost consequences Methods A prospective cohort study using linked questionnaire and medical record data from 806 low back pain patients in 8 UK general practices comparison of 116 144  who received a sickness certificate versus 690 who did not receive certification The primary clinical measure was the Roland and Morris Disability Questionnaire RMDQ Data on back pain consultation and work absenteeism were used to calculate healthcare and societal costs Results Participants issued a sickness certificate had higher backrelated disability at baseline consultation and 6month followup mean difference 31 95  CI 18 44 on the RMDQ indicating worse health status After fully adjusting for baseline differences most changes in clinical outcomes at 6 months were not significantly different between study groups Productivity losses were significantly higher for the certification group with most absence occurring after the expected end of certification mean difference in costs due to absenteeism over 6 months was £1956 95  CI £941 £3040 Conclusions There was no clear evidence of a difference in clinical outcomes between individuals issued a sickness certificate and those not issued a certification for their back pain With little overall contrast in clinical outcomes policy makers and care providers may wish to draw on the likely difference in societal costs alongside issues in ethical and moral care in their consideration of patient care for low back painBack pain is common in the workplace and the community at large and its disabling characteristics render it a significant burden to society In the United Kingdom UK the 1month prevalence of low back pain in the adult general population pain lasting 1 week has been estimated to be 23  1 One in seven consultations in primary care is for musculoskeletal pain with back pain being the most common reason for consultation at an annual rate of 591 people per 10000 registered persons 2It is well known that back pain has a major impact on productivity at work In the UK annual costs of back pain have been estimated as £16 billion for direct healthcare costs including consultations with healthcare professionals hospital outpatient visits and inpatient days and £107 billion for indirect factors including informal care and workplace productivity costs 3 In most countries a sickness certificate sanctions absence from work although issuing requirements differ between countries In the UK a sickness certificate is required for periods of work absence in excess of 7 days 4Musculoskeletal disorders and mental disorders are the most frequent reasons for sickness certification 4 5 6 7 and the most common causes of longterm work absence 8 In the UK approximately onethird of back pain general practice consulters are issued a sickness certificate 9 Aside from workplace factors little is known about the comparative clinical features of patients who are issued a sickness certificate compared to those who are not conceivably patients issued a certificate have greater physical impairment that interferes with their ability to perform usual work activities Despite the high rates of sickness certification and possible rationale for alleviating work difficulties through sickness certification recent research suggests that it may not be clinically effective 10 and several studies have shown that sickness absence and certification is associated with increased risk of longterm disability and subsequent award of a disability pension 11 12 13 14 15 16 There is little data contemporaneously comparing the clinical and cost outcomes of patients who receive a sickness certificate with those who do notIn light of this evidence on high costs particularly through workplace productivity loss the UK government commissioned health and work as a key priority target for public policy setting recommendation and guidelines for the provision of alternative/altered work duties for workers unable to perform their usual job activities 17 18 19 Although plausible that this strategy will lead to reduced cost to society there is no clear data or evidence to date to steer primary care policy makers and providers as to whether the strategy would be associated with improved clinical outcomes or reduced healthcare or societal costsCurrent recommendations about care of low back pain in primary care encourage patients to stay active including work and highlight the importance of selfmanagement whilst advocating the use of the Back Book for simple clinical guidelines 20 21 However Bishop et al 22 showed that current attitudes and behaviours of general practitioners and physiotherapists towards patients with low back pain are diverse and that many practitioners wrongly held the belief that patients should avoid activities and work Gerner and Alexanderson 23 reported that physicians were often faced with difficult and distressing decisions with regards to sickness certification and that potential discordance in doctor–patient opinions was highly likely since sickness certification legislation is based on impaired work ability by assessment In all Soler and Okkes 24 asserted that sick certification was “an unwelcome administrative burden for the family doctor” It could be argued that this burden and contention in its use needs to be balanced against ethical considerations in relation to such issues as the need to express empathy and provide compassionate care reduce unnecessary pain and suffering prevent an exacerbation of symptoms or to avoid embarrassment and stigmatization at workThis study aimed to 1 compare clinical and demographic characteristics between patients issued a sickness certificate by their general practitioner GP for their low back pain and those who are not issued a certificate 2 evaluate whether or not issuing sickness certificates is associated with clinical outcomes and 3 estimate the cost consequences associated with sickness certificationThis study is based on a longitudinal dataset describing the characteristics and clinical outcomes of patients from the Beliefs about Back Pain BeBack cohort 25 a prospective observational cohort study that recruited consecutive back pain consulters receiving usual primary care aged 18–60 years from eight GP practices in North Staffordshire and Cheshire The GP practices cover a heterogeneous sociodemographic population mix in terms of urban/rural profiles The BeBack study used mixedmethods to investigate patients’ illness perceptions and psychological obstacles to recovery in relation to back pain 25 26 and investigate health care professionals’ general practitioners and physiotherapists beliefs and attitudes about low back pain 27 28

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