Managing Sickness Absence of Patients with Musculoskeletal Pain – A Cross-sectional Survey of Scandinavian Chiropractors
SOURCE: Chiropractic & Manual Therapies 2019 (Jan 11); 27: 1
Mette Jensen Stochkendahl, Casper Glissmann Nim, Eleanor Boyle, Ole Kristoffer Larsen, Iben Axén, Ole Christian Kvammen and Corrie Myburgh
Nordic Institute of Chiropractic and Clinical Biomechanics,
Campusvej 55, DK-5230
Odense M, Denmark.
BACKGROUND: Musculoskeletal pain is a major cause of work disability. Many patients with musculoskeletal pain seek care from health care providers other than their general practitioners, including a range of musculoskeletal practitioners. Therefore, these musculoskeletal practitioners may play a key role by engaging in sickness absence management and work disability prevention. This study aimed to determine the prevalence of musculoskeletal practitioners’ practice behaviours, and their perceptions and beliefs about sickness absence management by using Scandinavian chiropractors as an example, as well as to examine the association between these characteristics and two different practice behaviours.
METHODS: As part of a mixed-methods study, we surveyed members of the national chiropractic associations in Denmark, Norway, and Sweden in 2016. Descriptive statistics were used to describe prevalence. Multilevel logistic regression with backwards stepping was used to estimate odds ratios with 95% confidence intervals between each of the two practice behaviours and the characteristics.
RESULTS: Out of the 802 respondents (response rate 56%), 372 were Danish, 349 Norwegian, and 81 Swedish. In Denmark and Norway, 38.7 and 37.8% always/often considered if sick leave was appropriate for their patient compared to 21.0% in Sweden (p = 0.007); and 86.5% of the Norwegian chiropractors always/often recommended to return-to-work versus 64.5 and 66.7% in Denmark and Sweden respectively (p < 0.001). In the final models, factors associated with the two practice behaviours were age, level of clinical experience, working as a teacher, the tendency to be updated on current legislations and policies using social services, contact with general practitioners, relevance of engagement in SAM, consideration of workplace factors, SAM as part of the clinical tool box, patient out-of-pocket fee, and recommending fast return-to-work.
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CONCLUSIONS: Whilst not always engaged in sickness absence management with regards to musculoskeletal pain, chiropractors favour a ‘return-to-work’ rather than a ‘stay-at-home’ approach. Several practice behaviours and perceptions and beliefs are associated with these outcomes; however, system or organisational barriers are linked to clinician non-engagement.
KEYWORDS: Absenteeism; Chiropractic; Occupational health services; Policy; Return to work; Work disability prevention
From the FULL TEXT Article
Musculoskeletal pain is a major cause of work disability with socioeconomic consequences. Back pain-related disorders alone are enormously costly and are responsible for up to one quarter of days off from work. Across Scandinavia [1, 2], four out of ten sickness certifications are based on a musculoskeletal diagnosis. 
In many parts of Europe, health reforms have focussed on shifting secondary care services into the community. However, the effort to reduce key cost drivers, such as second level diagnostic procedures and medical specialists, has resulted in a growing pressure on the general practitioners (GP). [4, 5] The GPs’ traditional gatekeeper role has become a particular point of stress, as this function is becoming administratively complicated and time consuming. In the area of work-related musculoskeletal healthcare, one response to this status quo has been to decentralise and delegate some functions to appropriately qualified auxiliary healthcare practitioners. Dealing with the ever-increasing demands for providing sickness certification is a contemporary example of where this kind of shift is occurring. Physiotherapists, chiropractors, and manual therapists are increasingly becoming the first point of contact and the principal provider of healthcare for individuals with musculoskeletal conditions. [6, 7]
For example, private sector musculoskeletal practitioners cater to approximately 25% of the healthcare seekers for back pain in the UK , and at least one third of back pain patients in Denmark choose to see a chiropractor.  Many of these patients may not see another health practitioner about their back pain.  With the substantial cost implications of work disabilities for national economies and the increasing care provided exclusively by musculoskeletal practitioners, there is a large potential for integration of work disability prevention in the model of care provided by these practitioners.  Further, data from previous studies have indicated a potential for cost-effectiveness by including musculoskeletal practitioners in occupational health services. [11–13]
This paper presents a cross-sectional, population-based survey, which is the second phase of a two-phased sequential, exploratory mixed-methods study. The first phase of the study involved a qualitative case study.  The interviews reported in the qualitative phase identified perceived barriers and facilitators, as well as practice behaviours of a group of musculoskeletal practitioners (chiropractors) with regards to sickness absence management (SAM) of their patients. These findings directly contributed to the development of the questionnaire used in this paper. In both phases of the study, we used a cohort comprised of Danish, Norwegian, and Swedish chiropractors as an example of a specialist healthcare practitioner group within the area of musculoskeletal health. In Denmark, Norway, and Sweden, chiropractors function as primary care sector practitioners and as first point of contact for patients with musculoskeletal disorders. The Scandinavian chiropractors receive their chiropractic education in various English-speaking countries (e.g., England, USA) or in Denmark, and are integrated at different levels in their healthcare system. But, the most noticeable difference is that since 2008, the Norwegian chiropractors have been licensed to certify sickness absence up to 12 weeks. A full overview of the differences is provided elsewhere. 
In the first phase, we found that the chiropractors’ practice behaviour was governed by the national legislations and policies of their respective countries. The rationale for engaging in SAM was related to the perceived level of competencies, an obligation to society, and to optimise favourable patient trajectories. For some chiropractors, SAM was highly integrated in their clinical care, but for others, it was not. The perceived barriers for engaging in SAM were related to patients’ and other stakeholders’ definition of the chiropractors’ scope of practice, patient out-of-pocket expenses, the administrative burden versus level of honorarium, and the lack of communication with other stakeholders.