Difficulties with the sickness certification process in general practice and possible solutions: A systematic review

Figures & data

Figure 1. Flow chart describing the selection of articles to be reviewed.

Table I. Problematic themes and issues encountered by GPs in issuing sickness certificates, along with possible solutions.

		Solutions
Themes	Issues	Proposed	Implemented	Assessed for validity	Assessed for effectiveness
Patient assessment	Body function (14–21) Activity and participation (10,16–19,21–36) Environmental factors (10,16,17,21,22,26, 27,31,35,37–43) Personal factors (22,23,27,31,37,38,40) Duration and degree of sickness certification (18,32,33,38,44)	To identify and systematize consensual decision criteria for sick-listing decision (18,26) To teach management of sickness certification at university or through CME (10,20,33,34, 42,45) To define consensual rules for cooperation between GPs and other stakeholders, especially OPs (16,26) To entrust sickness certification to insurance or OPs, or to multidisciplinary teams, including psychologists, physiotherapists and physicians (10,40,45) To entrust sickness certification to physiotherapists for musculoskeletal patients (24) To extend the time allowed for patient self-declaration (45)	GPs assessing patient work capacity at the outset and again after a given period of time (17) GPs getting support from insurance or occupational physicians for difficult cases (10)	SF-36 bodily pain score predicts over one-year work disability (14) F^b, C^a,SE^c Acute low back pain screening questionnaire (ALBPSQ) predicts risk of prolonged sick leave for neck pain patients (15) P^b, C^a, NL^c	Detection of psychiatric disorders in long-term sickness absence using common mental disorder screening questionnaire (CMD-SQ) followed by a psychiatric examination improved the rate of return to work for patients without a psychiatric sick-leave diagnosis (46) F^b, RCT^a, DK^c Educating GPs on functional assessment based on an ICF-derived checklist, improved their knowledge of patients’ workplace and perceived stressors, and increased the rates of partial sick leave (22,23) F^b, RCT^a, NO^c Undergraduate training in social insurance medicine increased the certification rate of musculoskeletal patients (8) F^b, CS^a, SE^c Entrusting management of patients with work injuries and occupational diseases to OPs reduced the frequency and length of sick leave (47) P^b, B/A^a, HR^c
Doctor-patient relationship	Discrepancy between GP and patient opinions on the need for sick-leave (19,25,27,32,34,37,48–53) Physician's dual role (10,19,25,32, 34–37,43,50,53–56) Physician's “liberal attitude” (49,55,57,58)	To provide institutional support to GPs (10,25,53) More experienced doctors being mentors for their frustrated colleagues (49) To teach negotiating care and handling of conflicts with patients (27,34,48,50,51)	GPs getting support from insurance or OPs for difficult cases (10,32)		A workplace policy on sick-listing was associated with lower reporting of specific problems (25) G^b, CS^a, SE^c
Healthcare organization	Lack of knowledge in sickness insurance legislation (18,35,36,59) Lack of support and management (10,16,19,24,43,48,53, 60,61) Lack of cooperation between GPs and OPs (30,53,57, 62,63) Prolongation of sick leave initially provided by other physicians (32,44) Lack of time during consultation (10,27,43,57) Waiting period to obtain medical appointment or investigation (27,32,57)	To teach sickness certification management at university and through CME (27,30,48,61,63) To teach cooperation between GPs and OPs at university and through CME (57,59,61,63) To define consensual rules for cooperation between GPs and other stakeholders, especially OPs (53) To refer difficult cases to an authoritative professional such as a regional medical officer (45,55) To entrust sickness certification to insurance or occupational physicians, or to multidisciplinary teams, possibly including psychologists, physiotherapists, nurses and physicians (16,24,30,59)	GPs declare improving their competence in sickness certification through contacts with colleagues and patients (64)	A more flexible certification form applied to vignettes was associated with a higher provision of written fitness for work advice (60) F^b, CS^a, UK^c	Since the Swedish legislation reform for sickness certificates (1995), sick listing rates and length have not decreased, but certificates have been filled out more completely (65,66) F^b, P^b, B/A^a, SE^c Department of Work and Pension guidelines on sick-listing (2002) are poorly known and used by GPs (61) F^b, CS^a, UK^c GPs receiving guidelines about sickness certification improved the quality of management and the exhaustiveness of information on the certificates (67) P^b, B/A^a, SI^c Common training courses for GPs and OPs, based on a collaborative protocol for low back pain treatment, did not improve patient functional status or sick leave length (62) F^b, CIT^a, NL^c
Socio-economic environment	Lack of workstation adaptation by employers (27,31) Inadequacy between labour market requirements and patient health (10,27,31) Economic burden for social insurance (65,66)	To improve cooperation between GPs and OPs (31) To develop a healthier working environment based on ergonomic principles (10,31)

GPs = general practitioners; OPs = occupational physicians; CME = continuing medical education; ICF = International classification of functioning, disability and health; SF-36 = short-form 36 items health questionnaire.

^aAbbreviations referring to the study design: B/A = Before/after; C = Prospective cohort study; CIT = Controlled intervention trial; CS = Cross sectional study; RCT = Randomized controlled trial. ^bAbbreviations referring to study quality: G = good, F = fair, P = poor.

^cAbbreviations referring to the country under survey: DK = Denmark; HR = Croatia; NL = The Netherlands; NO = Norway; SE = Sweden; SI = Slovenia; UK = United Kingdom.

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