RESEARCH ARTICLE Open Access
Compa ing occasional and pe sis en
equen a ende s in occupa ional heal h
p ima y ca e –a longi udinal s udy
Tiia Reho
1,2*
, Salla A kins
1,3
, Nina Talola
1
, Ma kku Sumanen
1
, Me i Viljamaa
2
and Jukka Ui i
1,4,5
Abs ac
Backg ound: The aim o he s udy was o compa e occasional and pe sis en equen a ende s in occupa ional
heal h (OH) p ima y ca e and o iden i y he diagnoses associa ed wi h pe sis ing equen a endance.
Me hods: This is a longi udinal s udy using elec onic medical eco d da a om 2014 o 2016 om an OH se ice
p o ide . F equen a ende s we e de ined as pa ien s in he op decile o annual isi s o heal hca e p o essionals
( equen a ende 10%, FA10). FA10 we e ca ego ized o h ee g oups acco ding o he pe sis ence o equen
a endance (1-yea -FA, 2 yea -FA, and pe sis en -FA = equen a ende s in all h ee yea s). This was used as he
dependen a iable. We used pa ien sex, age, employe size, indus y and dis ibu ion o isi s and diagnos ic
codes o cha ac e ize he di e en equen a ende g oups.
Resul s: In o al, 66,831 pa ien s we e included, o which 592 pe sis en equen a ende s (0.9% o he s udy popula ion)
consul ed he OH uni on a e age 13 imes a yea . They made al oge he 23,797 isi s du ing he s udy yea s. The
p opo ion o women and employees o medium and la ge employe s inc eased among pe sis en -FAs when compa ed
o he o he g oups. Mul inomial logis ic eg ession accen ua ed musculoskele al diso de s and o a lesse ex en diseases
o he espi a o y and ne ous sys em and men al diso de s. One in i e FA becomes a pe sis en -FA.
Conclusions: Ou esul s indica e ha in he con ex o a wo king popula ion he associa ion o musculoskele al diso de s
and pe sis en equen a endance is emphasized. Pe sis en equen a ende s also c ea e a subs an ial demand
on physician esou ces. When planning in e en ions aimed a wo king age equen a ende s, subg oups su e ing
om musculoskele al diso de s should be iden i ied as hey a e associa ed wi h pe sis ing equen a endance.
Keywo ds: F equen a ende , High use , High u ilize , Occupa ional heal h se ices, Pe sis en equen a endance,
P ima y heal h ca e, Heal h ca e u iliza ion, Longi udinal s udies
Backg ound
F equen a ende s demand a subs an ial po ion o
physician’s ime and consume a conside able sha e o
heal h ca e esou ces [1–3]. Some pa ien s consul hei
physician epea edly o a sho pe iod and e u n o an
i egula pa e n o a endance a e some ime [3,4].
Ano he g oup o pa ien s, o en e e ed o as pe sis en
equen a ende s, isi heal h ca e p o ide s equen ly
one yea a e ano he [3,5]. Though s udies on pe sis en
equen a endance a e spa se, and concen a e on a
gene al p ac ice se ing, i appea s ha a combina ion
o soma ic, psychological and psychia ic, and social ac o s
lead o pe sis en equen a endance [4–6]. In o de o
pu pose ully di ec esou ces and o p o ide adequa e ea -
men and ehabili a ion, we need o be able o ecognize
indi iduals a isk o con inuous high use o se ices wi h
he ou ine da a a ailable du ing consul a ions. In addi ion,
he di e en ia ion o occasional and pe sis en equen
a ende s could be use ul o se ice planning as s udies
sugges ha pe sis en FA’s consume an e en la ge
p opo ion o physicians ime yea ly han occasional FA’s,
and p esen mo e social p oblems and highe mo bidi y
[3,5] han occasional FA’s.
* Co espondence: [email p o ec ed]
1
Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, PB 100,
FI-33014 Tampe e, Finland
2
Pihlajalinna Työ e eys, Tampe e, Finland
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Reho e al. BMC Public Heal h (2018) 18:1291
h ps://doi.o g/10.1186/s12889-018-6217-8
P e ious esea ch sugges s ha equen a ende s su e
om mul imo bidi y [6,7] and low quali y o li e [8].
S udies also indica e ha unemploymen is associa ed
wi h equen a endance especially among men [9,10]
bu ew s udies hus a ha e concen a ed on equen
a endance among he wo king popula ion [11]. S udies
conduc ed in gene al p ac ice o seconda y ca e se ing do
no add ess he demands o he wo king li e. Gi en ha
wo k has bene icial e ec s on heal h [12] bu also places
demands on wo k abili y, he wo king popula ion should
be examined also sepa a ely. S udying he wo king popu-
la ion could yield di e en esul s possibly emphasizing
illnesses ha es ic wo k abili y. Finnish occupa ional
heal h (OH) p ima y ca e is an app op ia e en i onmen
o s udy equen a ende s in wo king popula ion, as i
co e s 90% o he employees [13] and main ains comp e-
hensi e heal h eco ds.
Visi s o occupa ional heal h se ices (OHS) p ima y
ca e a e associa ed wi h ch onic illnesses a ec ing wo k
abili y and wo k ela ed symp oms [14]. Ch onic heal h
issues a e also associa ed wi h lowe p oduc i i y a
wo k [15] and lowe ed wo k abili y, which suppo s hei
being ea ed and managed in OHS. The mos common
wo k- ela ed isi s o he OH physician a e musculoskele al
and men al diso de s [16],whicha ebo halsoleading
causes o disabili y in Finland [17] and linked o equen
a endance in gene al p ac ice se ing and OH p ima y ca e
[11,18,19]. This sugges s ha equen a ende s in OH
p ima y ca e migh be a ulne able g oup o pa ien s
demanding ca e ul assessmen o wo k abili y, wo k
ela edness and ollow up. Gi en he complexi y o equen
a ende s’condi ions and he esou ce demand hey c ea e,
i is c ucial ha hei condi ions a e iden i ied as ea ly as
possible. I is also pe inen o di e en ia e cha ac e is ics
and ac o s associa ed wi h occasional and pe sis en
equen a endance o de e mine which g oups need
OH in e en ions. Iden i ying he isk g oups would
allow a ge ed OH examina ions, whe e heal h plans
and necessa y ehabili a i e measu es and wo k place
in e en ions can be planned o p e en disabili y [20].
We aimed o compa e occasional and pe sis en equen
a ende s and o de ine ac o s associa ed wi h pe sis en
equen a endance in OH p ima y ca e.
Ma e ial and me hods
S udy se ing and design
P ima y heal h ca e se ices in Finland a e o ganized in
h ee pa allel s uc u es: municipal, p i a e and occupa ional
heal h ca e (OH). P e en i e occupa ional heal h se ices
a e manda ed by law and employe s a ange hese se ices
o employees. In addi ion mos employe s a ange o he
same heal h ca e p o ide ha p o ides legisla i e se ices
also o p o ide p ima y ca e se ices o employees –
OH p ima y ca e co e s app oxima ely 90% o he wo king
o ce [13].
This is a longi udinal e ospec i e s udy using ou ine
medical eco d da a om a la ge p i a e OHS p o ide
Pihlajalinna Työ e eys which has 40 OH uni s a ound
he na ion. A longi udinal s udy design was chosen o
analyze p edic i e ac o s associa ed wi h pe sis ing equen
a endance. Pihlajalinna Työ e eys’clien s ep esen he
wo king popula ion o Finland including companies om a
wide ange o indus ies and u al as well as u ban a eas. In
OHS p ima y ca e pa ien s can use se ices o di e en
heal h ca e p o essionals who a e usually specialized in
occupa ional heal h: physicians, nu ses, physio he apis
and psychologis s. A e e al om a nu se o physician
is equi ed o a physio he apis o psychologis consul -
a ion and physicians can consul o he medical specialis s.
In Finland occupa ional heal h nego ia ions ( e e ed o as
OH collabo a i e nego ia ion) [21] a e held con iden ially
be ween he occupa ional heal h physician, employee and
employe whene e conce ns a e aised on he indi iduals
wo k abili y.
Da a collec ion
Ou da a consis ed o ou ine in o ma ion, including
diagnos ic codes, en e ed du ing all isi s o heal hca e
p o essionals in 2014–2016. The da a also included
backg ound da a, such as age and sex o he employee
and employe ’s size and indus y. In o ma ion on OH
collabo a i e nego ia ions held was also ob ained. The da a
we e collec ed by Pihlajalinna and sen in pseudonymized
o m o he Uni e si y o Tampe e. Pseudonymiza ion was
ca ied ou by Pihlajalinna Työ e eys and Uni e si y o
Tampe e ecei ed he da a including only ID-numbe
han canno be associa ed wi h a single pa ien . The
co esponding social secu i y numbe and ID-lis was kep
by Pihlajalinna. Based on Finnish legisla ion (Pe sonal Da a
Ac , Finland, 22.4.1999) indi idual consen is unnecessa y
since no indi idual could be iden i ied due o he size o
he s udy popula ion.
Ou ini ial da a comp ised 78,507 pa ien s. The s udy
ma e ial was limi ed o employees aged 18–68 yea s
who had isi ed he OHS p ima y ca e ace- o- ace a
leas once du ing he s udy yea s. All gene al and
manda o y heal h check-ups and con ac s no conduc ed
ace- o- ace (p esc ip ion enewals, elephone calls e c.)
we e excluded based on in oice codes. Gene al and
manda o y (occupa ional) heal h check-ups we e ex-
cluded as hey a e no ini ia ed by he pa ien no a e
hey necessa ily illness ela ed. A e hese exclusions
ou s udy comp ised 66,831 pa ien s. Diagnos ic codes
(ICD-10) egis e ed o each physician isi we e collec ed
and he i s (i.e. he main) diagnosis was used in he
analysis.
Reho e al. BMC Public Heal h (2018) 18:1291 Page 2 o 9
S a is ical analysis
F equen a endance was de ined as op decile o a ende s
[3,22]. Visi s o physicians, nu ses, physio he apis and
psychologis s we e used o de e mine he op decile o
a ende s ( equen a ende 10%, FA). Pa ien s we e hen
ca ego ized in o ou g oups o analysis. Those pa ien s
ha we e in he op decile o a ende s in one o he s udy
yea s (2014, 2015 o 2016) we e named 1-yea -FA (1yFA).
The pa ien s ha we e in he op decile in any wo s udy
yea s we e named 2-yea -FA (2yFA). Those pa ien s
ha we e in he op decile in all h ee s udy yea s we e
conside ed pe sis en equen a ende s (pFA). Pa ien s
ha we e ne e in he op decile we e conside ed as a
e e ence g oup, non- equen a ende s (non-FA). A low
diag am o pa ien ca ego iza ion and loss o ollow up is
shown in diag am 1 (Fig.1).
The s udy popula ion was di ided in o ou age g oups
(18–34, 35–44, 45–54, 55–68) and u he by sex. In u he
analysis no age s a i ica ion was done since he whole s udy
popula ion consis s o wo king age popula ion. Employe s
we e ca ego ized acco ding o numbe o employees
(mic o 1–10, small 11–50, medium 51–250 and la ge >
251 employees). The employe indus y was classi ied
acco ding o S a is ics Finland (TOL2008/Nace Re . 2)
and he 10 la ges indus ies we e analyzed sepa a ely and
he 10 smalle indus ies we e combined as one g oup
(o he s). Diagnoses egis e ed a he physician isi s we e
ca ego ized acco ding o he chap e headings o ICD-10.
ICD-10 subg oups we e de ined in mo e de ail based on
p e ious li e a u e [3,18,19] and o examine he la ges
diagnos ic g oups mo e closely [11].
Desc ip i e s a is ics we e used o examine demog aphic
da a, OH collabo a i e nego ia ion and backg ound da a
including employe size and indus y o he equen
a ende s g oups (1yFA, 2yFA, pFA o non-FA). Di e ences
be ween he g oups in cha ac e is ics we e analyzed using
Pea son’s chi-squa e. One-way ANOVA es s was used o
analyze he numbe o isi s o di e en heal h ca e p o es-
sionalsasawholeand hedis ibu ion o isi s be ween
di e en p o essional g oups. K uskal-Wallis – es was used
o analyze di e ences be ween he g oups in he numbe o
diagnoses. In mul inomial logis ic eg ession he ou come
a iable was ca ego ized in o ou : non-FA, 1yFA, 2yFA
andpFA.Weused henon-FAg oupasa e e ence
g oup. The analysis was adjus ed by sex, age, employe ’s
ield o indus y and size. Odds a ios (OR) wi h 95%
Fig. 1 Flow diag am o pa ien ca ego iza ion in o FA10 and non-FA. FA10 = he op decile o a ende s ( equen a ende 10%, FA10). non-FA = pa ien s
ha we e ne e in he op decile we e conside ed as a e e ence g oup, non- equen a ende s
Reho e al. BMC Public Heal h (2018) 18:1291 Page 3 o 9
con idence in e als (95% CI) we e de e mined o each
ac o (p o essionals isi ed, diagnosis). P alues unde
0.05 we e conside ed s a is ically signi ican . S a is ical
analyses we e pe o med wi h IBM SPSS S a is ics e sion
23 (IBM Co p., A monk, NY, USA) so wa e by NT.
Resul s
The s udy popula ion a e exclusions comp ised 66,831
pa ien s (2014–2016). When di ided in o ou ca ego ies
592 (0.9%) pa ien s we e pFAs, 1603 (2.4%) 2yFAs, 6528
(9.8%) 1yFAs and 58,108 (86.9%) non-FAs. P opo ionally
mo e women (50% o 1yFA, 53% o 2yFA and 56% o pFA)
han men we e equen a ende s (and he p opo ion o
women inc eased in 2yFAs and pFAs). F equen a ende s
we e p edominan ly employed in medium and la ge com-
panies (Table 1). The h ee la ges indus ies employing
equen a ende s we e manu ac u ing, public adminis a-
ion and human heal h and social wo k (da a no shown).
The use o o he p o essionals besides physicians inc eased
as equen a endance con inued. 2yFAs and pFAs consul
wi h a psychologis s, physio he apis s and specialis s
mo eo en hannon-FAsand1yFAsdo.Inaddi ion,
he likelihood o occupa ional heal h nego ia ion inc eased
as equen a endance pe sis ed. See Table 1 o u he
cha ac e is ics.
The a e age and mean consul a ion a es can be seen
in Table 2. Pe sis en equen a ende s consul wi h a
heal hca e p o essional yea ly o e i e imes mo e han
non-FAs do. The di e ences be ween consul a ion a es
we e no able in physician consul a ions bu he same
end was seen also wi h o he heal h ca e p o essionals.
O e he h ee s udy yea s, pFAs a ended hei OH p ima y
ca e uni 40 imes on a e age whe eas a non-FA isi ed on
a e age 4 imes. Mos o hese consul a ions we e doc o ’s
appoin men s. O e he h ee yea pe iod physio he apis s
we e consul ed on a e age 1.3, 2.6, 4.0 and 0.2 imes
(md 0, 1, 2 and 0) by 1yFA, 2yFA, pFA and non-FA espec -
i ely. O e he same pe iod psychologis s we e consul ed
on a e age 1.4 imes by pFA and 0.6, 1.3 and 0.08 imes
(md 0) by 1yFA, 2yFA and non-FA espec i ely.
Table 3includes he dis ibu ion o diagnoses o 1yFA,
2yFA, pFA and non-FA. When examining he diagnos ic
codes egis e ed o each physician isi , he mos common
diagnos ic codes o any g oup we e diseases o he espi a-
o y sys em and o he musculoskele al sys em. Diseases
o he musculoskele al sys em we e o e ep esen ed in
equen a ende g oups and hei equency inc eased
owa ds pe sis en equen a endance. The same end is
isible in all he diagnos ic g oups and is accen ua ed also in
men al and beha iou al diso de s, inju ies and unclassi ied
symp oms. Du ing he h ee s udy yea s a e age numbe o
di e en diagnoses was 4.2 (md 4), 5.8 (md 6), 6.9 (md 7)
and 2.0 (md 2) o 1yFA, 2yFA, pFA and non-FA espec -
i ely (p< 0.001, K uskal-Wallis - es ).
Table 4shows he adjus ed OR o ac o s associa ed
wi h equen a endance o a ying leng hs. The same
ICD-10 ca ego ies domina ed in all h ee ca ego ies bu
he p opo ions di e ed o some ex en . Among pFA
diseases o he musculoskele al and espi a o y sys em
had he highes odds, ollowed by unclassi ied symp oms
(R00-R99). On he o he hand among 1yFAs musculo-
skele al and men al diso de s we e he leading diagnoses
and diseases o he ne ous sys em had he hi d highes
OR. Among 2yFAs musculoskele al and espi a o y diseases
domina ed bu men al and beha iou al diso de s we e hi d
mos common. Diseases o he ne ous sys em and inju ies
s ood ou in all h ee FA ca ego ies. When examining he
ICD-10 F-codes mo e closely we no ed ha o dep essi e
episodes he adjus ed OR o pFA was 12.0 (95% CI
9.5–15.2) and o phobic diso de s 8.5 (95% CI 6.5–
11.0). Fo illnesses o he back and spine OR o pFA
was 13.5 (95% CI 11.3–16.1) and illnesses o he neck,
ce ical spine and ension headache he OR was 10.47
(95% CI 8.9–12.4). Fo illnesses o he uppe ex emi ies
he OR was 8.9 (95% CI 7.5–10.5) and o illnesses o he
lowe ex emi ies 7.9 (95% CI 6.7–9.4). Again, o pFA he
OR o as hma and COPD was 8.3 (95% CI 6.4–10.7)
while o acu e uppe espi a o y in ec ions he OR was
13.4 (95% CI 10.7–16.9) (da a no shown). We also saw
ha psychologis and physio he apis use was associa ed
wi h 2yFAs and pFAs (Table 4). The OR inc eases o e
yea s when equen a endance con inues especially
wi h ega d o physio he apis , psychologis , and specialis
consul a ions.
Discussion
Nea ly one in i e equen a ende s in 2014 con inued
equen use o se ices o he ollowing wo yea s. Pe -
sis en FAs a e equen ly women and employed in
medium and la ge en e p ises. Musculoskele al diso de s
a e mo e closely associa ed wi h pFA han o he diagnos ic
g oups. The associa ion wi h men al diso de s weakens as
equen a endance con inues. The easons o his e ec
should be examined u he .
This s udy e i ies in Finnish OH p ima y ca e en i on-
men ha pe sis en equen a ende s c ea e p opo ionally
he mos demand o he heal h ca e uni as p e iously seen
in gene al p ac ice (GP) se ing [3]. The use o se ices and
in pa icula physician consul a ions is subs an ial compa ed
o non-FAs and also 1yFAs and 2yFAs. The pFA g oup o
592 pa ien s made 23,797 isi s o hei p ima y ca e uni
du ing he h ee s udy yea s. Gi en he cos o a physician
isi compa ed o isi s o o he heal h ca e p o essionals,
he economic e ec c ea ed by his small g oup is no able.
In ou s udy nea ly one ou o i e (19%) o FAs in 2014
con inued as pe sis en equen a ende s, which is sligh ly
mo e han in a Du ch s udy in gene al p ac ice se ing [3].
While he g oup o pFAs cons i u ed 0.9% o he s udy
Reho e al. BMC Public Heal h (2018) 18:1291 Page 4 o 9
popula ion, hey made 6% o all isi s in he h ee s udy
yea s. The h ee equen a ende g oups (pFA, 2yFA and
1yFA) made up in o al 40% o all consul a ions.
Ou s udy is he i s o desc ibe how he use o o he
heal hca e p o essionals a ies be ween occasional and
pe sis en equen a ende s. Visi s o physio he apis s
and psychologis s we e associa ed wi h pe sis ing equen
a endance in pa icula and ha ing consul ed ei he hem
o a specialis inc eases he OR o belonging o pFA o
almos 15. In his s udy we desc ibed how equen
a ende s consul o he heal hca e p o essionals. I appea s
ha al hough he use o physio he apis s and psychologis s
inc eases wi h pFAs, he dominance o physicians’appoin -
men s is ma ked. P e iously, in a GP se ing specialis
consul a ions ha e been linked o equen a endance
and use o mul iple heal hca e se ices o mul imo bidi y
[7,23]. Ou s udy e i ies he associa ion o specialis
consul a ion and equen a endance and speci ies he
associa ion wi h pa icula ly pe sis ing equen a endance.
The signi icance o musculoskele al diso de s accumu-
la es owa ds pe sis ing equen a endance. I diagnosed
wi h a musculoskele al diso de , he OR o being a pFA a e
o e 26- old (when adjus ed o age, sex, employee size and
indus y). Al hough he associa ion o musculoskele al dis-
o de s and equen a endance has been no ed p e iously
[18,24,25] i s signi icance seems emphasized in he wo k-
ing popula ion. P e ious s udies no ed ha musculoskele al
diso de s a e associa ed wi h isi s o OH physicians and
a e one o he main wo k- ela ed easons o heal hca e
consul a ions [26,27], which migh explain his esul in
Table 1 S udy popula ion 2014–2016, cha ac e is ics o 1-yea -FA, 2-yea -FA, pFA and non-FA (n= 66,831)
Cha ac e is ics 1-yea -FA
2014–2016
2-yea -FA
2014–2016
pFA
2014–2016
non-FA
2014–2016
p alue
n(%) n(%) n(%) n(%)
6528 (10) 1603 (2) 592 (1) 58,108 (87)
Sex < 0.001
Male 3270 (50) 754 (47) 262 (44) 33,236 (57)
Female 3258 (50) 849 (53) 330 (56) 24,872 (43)
Age < 0.001
18–34 1661 (25) 354 (22) 128 (21) 19,630 (34)
35–44 1641 (25) 413 (26) 147 (25) 13,648 (23)
45–54 1889 (29) 473 (30) 187 (32) 14,351 (25)
55–68 1337 (21) 363 (22) 130 (22) 10,479 (18)
Company size < 0.001
0–10 507 (8) 77 (5) 19 (3) 8544 (15)
11–50 1601 (25) 350 (22) 129 (22) 16,036 (28)
51–250 1767 (27) 513 (32) 195 (32) 14,165 (24)
> 250 2287 (35) 663 (41) 249 (42) 16,451 (28)
Missing 2 (0) 16 (0)
Specialis consul a ion < 0.001
No 4677 (72) 894 (56) 244 (41) 51,622 (89)
Yes 1851 (28) 709 (44) 348 (59) 6486 (11)
P o essionals isi ed < 0.001
Physician 6513 (100) 1603 (100) 592 (100) 53,945 (93)
Nu se 4119 (63) 1192 (74) 460 (78) 18,918 (33)
Physio he apis 2932 (45) 1023 (64) 425 (72) 7910 (14)
Psychologis 1174 (18) 467 (29) 196 (33) 1966 (3)
OH collabo a i e nego ia ion (2014–2015) < 0.001
No 6309 (97) 1424 (89) 453 (77) 57,490 (99)
Yes 219 (3) 179 (11) 139 (23) 618 (1)
FA s a us was de ined as he op decile o a ende s ( equen a ende 10%, FA10)
1-yea -FA = Pa ien s ha we e in he op decile o a ende s in one o he s udy yea s (2014, 2015 o 2016)
2-yea -FA = Pa ien s ha we e in he op decile in any wo s udy yea s (2014, 2015 o 2016)
pFA = Pa ien s ha we e in he op decile in all h ee s udy yea s (2014, 2015 and 2016)
non-FA = Pa ien s ha we e ne e in he op decile we e conside ed as a e e ence g oup, non- equen a ende s
Reho e al. BMC Public Heal h (2018) 18:1291 Page 5 o 9

OH p ima y ca e. This esul sugges s ha among he
wo king age popula ion diseases o he musculoskele al
sys em can be a mo e impo an ac o d i ing equen
a endance han in he gene al p ac ice se ing. This is
an obse a ion ha should be aken in o accoun when
planning iden i ica ion and in e en ion s a egies o
equen a ende s in his con ex .
Ou indings sugges ha in pa icula hose equen
a ende s diagnosed wi h musculoskele al diso de s should
be iden i ied ea ly. A ollow up plan should be p epa ed,
whe eamul ip o essionalapp oachcouldbeusedin he
spi i o Good Occupa ional Heal h P ac ice and he Occu-
pa ional Heal h Ca e Ac [28]. The accumula ing p essu e
and weigh on he sys em om equen a endance is
signi ican and cos -sa ings migh be ob ained i u iliza ion
could be inc easingly planned and managed. Deepe analysis
behind easons o a endance [29] could be acqui ed
h ough collabo a ion wi h o he heal h ca e p o essionals.
OHS has close con ac wi h he employe s allowing,
wi h he consen o he employee, also wo kplace in e -
en ions i seen necessa y [30]. Al hough he likelihood
o OH collabo a i e nego ia ion inc eases as he equen
use o se ices con inues, hese nego ia ions ha e been
held o only 23% o pFA. Fu he s udies should in es iga e
i ha ing a ended an OH collabo a i e nego ia ion a ec s
u u e equen a endance. In e en ions aimed a equen
a endance ha e shown encou aging esul s when subg oups
such as dep essed pa ien s a e a ge ed o a de ailed analysis
o easons o a endance a e ca ied ou [29,31]. I wo k
ela ed symp oms and pe o mance di icul ies cause isi s
o OH uni , wo kplace in e en ions, including OH collab-
o a i e nego ia ions, migh be an e ec i e way o add ess
medically unsol able easons o a endance.
The associa ion wi h men al and beha iou al diso de s
also g ows as equen a endance pe sis s, bu diseases
o he espi a o y and ne ous sys em show highe odds
in associa ion wi h pFA. An Es onian s udy ound ha
dep essed pa ien s did no consul a physician signi ican ly
mo e han o he s when he ollow up pe iod was h ee
yea s [32]. E ec i e eco e y could explain his also in ou
s udy. Howe e as men al diso de s a e one o he mos
common easons o disabili y pensions, his issue should
be s udied u he . I is no known i equen a ende s
ecei e mo e disabili y pensions o men al diso de s han
o he s, which could also cause men al heal h diagnoses
being less signi ican in he pFA g oup. Also in Finland,
men al and beha iou al diso de s can also be ea ed
in men al heal h se ices and uni s o seconda y ca e.
I a men al diso de pe sis s, pa ien s a e o en e e ed o
hese uni s. This migh be one ac o explaining why men al
diso de s appea less signi ican wi h pFA g oup. Simila ly
o Aus alian and Du ch p ima y ca e s udies we ound ha
pe sis en equen a endance was associa ed wi h dep es-
sion, bu on he o he hand we did no ind an associa ion
wi h diabe es o hea p oblems [3,5]. This migh be due o
ou s udy ma e ial comp ising o solely a wo king age
popula ion, some o whom may consul public p ac i ione s
o ch onic diseases [26,33]. The OH p ima y ca e se ing
mos likely emphasizes he p oblems and illnesses a ec ing
wo king abili y [14].
The indings also indica e ha espi a o y diseases and
diseases o he ne ous sys em a e closely associa ed wi h
pe sis en high use o se ices in he wo king age popula-
ion. An associa ion o pe sis en high use o se ices wi h
espi a o y diseases has p e iously been epo ed in a
p ima y ca e se ing [3] and diseases o he ne ous sys em
ha e been associa ed wi h equen a endance, bu his con-
i ms he connec ion also in pe sis en equen a endance
Table 2 Associa ion be ween consul a ion isi s and equen
a ende s a us (n= 28,233–66,831)
Cha ac e is ics Consul a ions, all Physician Nu se
a . md a . md a . md
2014
(n= 28,233)
*** *** ***
1-yea -FA 4.9 4 3.6 3 0.7 0
2-yea -FA 7.7 8 5.6 5 1.1 0
pFA 13.2 11 9.6 9 1.8 1
non-FA 2.9 2 2.3 2 0.4 0
2015
(n= 31,960)
*** *** ***
1-yea -FA 5.7 5 4.1 4 0.8 0
2-yea -FA 10.2 9 7.3 7 1.4 1
pFA 14.3 13 10.6 10 1.8 1
non-FA 2.7 2 2.1 2 0.4 0
2016
(n= 47,981)
*** *** ***
1-yea -FA 7.8 8 5.5 5 1.2 0
2-yea -FA 9.4 9 6.7 6 1.2 0
pFA 12.6 11 9.4 8 1.5 1
non-FA 2.4 2 1.9 1 0.4 0
2014–2016
(n= 66,831)
*** *** ***
1-yea -FA 13.8 13 9.9 9 2.1 1
2-yea -FA 26.4 25 19.0 19 3.6 2
pFA 40.0 37 30.0 28 5.1 3
non-FA 4.0 3 3.1 2 0.6 0
One-way ANOVA – es , a . = a e age, md = median, p< 0.001 in all alues
FA s a us was de ined as he op decile o a ende s ( equen a ende
10%, FA10)
1-yea -FA = Pa ien s ha we e in he op decile o a ende s in one o he
s udy yea s (2014, 2015 o 2016)
2-yea -FA = Pa ien s ha we e in he op decile in any wo s udy yea s (2014,
2015 o 2016)
pFA = Pa ien s ha we e in he op decile in all h ee s udy yea s (2014, 2015
and 2016)
non-FA = Pa ien s ha we e ne e in he op decile we e conside ed as a
e e ence g oup, non- equen a ende s
Reho e al. BMC Public Heal h (2018) 18:1291 Page 6 o 9
[25]. In u n, he high OR o he ICD R-g oup can be seen
as indica i e o medically unexplained physical symp oms
(MUPS). The associa ion o MUPS wi h pe sis en equen
a endance has been seen also in gene al p ac ice se ing [3]
and is o impo ance as also medically unexplained symp-
oms inc ease he isk o long- e m sickness absence [34].
The inding ha inju ies ha e highe odds o pe sis en FA
is in e es ing, and migh ein o ce he pe cep ion ha pe -
sis en equen a ende s a e mo e ulne able as also indi-
ca ed in a p e ious s udy [35]. Mul imo bidi y is associa ed
wi h equen a endance and appea s o inc ease as e-
quen a endance pe sis s, as also seen p e iously [3]. As a
whole, no single ac o di e en ia es hese g oups om
each o he bu a he , hese ac o s seem o exis on a
con inuum.
Ou s udy has ce ain limi a ions. Ou s udy popula ion
di e s om he gene al p ac ice se ing o some ex en in
e ms o pa ien age and wo king s a us, and we assume
ha hese demog aphic di e ences possibly accen ua e
di e en ac o s han wha would ise in gene al p ac ice
se ing. The lack o occupa ional s a us and educa ion
a e limi a ions o he s udy as hese a e no a ailable in
medical eco ds. Human e o may be p esen when
using medical eco d da a, bu he la ge sample likely
dilu es he e ec . Re ospec i e s udy se s limi a ions o
a iables used, which a e also limi ed by wha is and
can be egis e ed in he elec onic pa ien egis e s.
On he o he hand ou da a allow a unique pe spec i e
o his pa icula g oup gi en ou na ionwide ma e ial
co e ing la gely di e en se ice sec o s and bo h u al
and u ban a eas wi h employees wi h a ie y o employmen
leng hs and indus ies. The dis ibu ion o employe s’size
and indus y esembles he gene al dis ibu ion o employe s
acco ding o S a is ics Finland [36]. The equal age dis ibu-
ion wi hin he wo king age popula ion and equal gende
dis ibu ion, allows gene aliza ion ou side his pa icula
con ex . S eng hs o he s udya ela gesampleandlongi u-
dinal s udy design allowing o in e p e a ion o p edic i e
ac o s o pe sis en equen a endance. The heal h ca e
eco ds in Finland a e accu a e and comp ehensi e allowing
o good quali y da a. Fo example, he ICD-10 classi ied
diagnos ic code was missing in only 1% o he isi s. In
his s udy we did no ha e access o use o o he heal h
ca e se ices, bu a p e ious s udy indica es ha when
OHS p ima y ca e is a ailable i is o en used as sole
p ima y ca e p o ide [26].
Conclusions
Diseases o he musculoskele al sys em a e emphasized
among pe sis en equen a ende s o occupa ional heal h
p ima y ca e. This could be explained by he demands o
wo king li e o ha he condi ions a e wo k- ela ed. As
i seems ha pe sis en equen a ende s c ea e he
mos demand o hei p ima y ca e uni , i is necessa y
Table 3 Pa ien s diagnosed wi h a disease acco ding o ICD-10 ( egis e ed o physician consul a ions in he s udy yea s 2014–2016,
n= 66,831)
Cha ac e is ics 1-yea -FA
2014–2016
2-yea -FA
2014–2016
pFA
2014–2016
non-FA
2014–2016
n(%) n(%) n(%) n(%)
6528 (10) 1603 (2) 592 (1) 58,108 (87)
ICD-10
J00-J99 Diseases o he espi a o y sys em 4254 (65.2) 1321 (82.4) 536 (90.5) 23,678 (40.7)
M00-M99 Diseases o he musculoskele al sys em and connec i e issue 4796 (73.5) 1422 (88.7) 559 (94.4) 21,303 (36.7)
R00-R99 Symp oms, signs and abno mal clinical and labo a o y
indings, no elsewhe e classi ied
2309 (35.4) 857 (53.5) 401 (67.7) 9147 (15.7)
S00-T98 Inju y, poisoning and ce ain o he consequences o ex e nal causes 2198 (33.7) 792 (49.4) 349 (59.0) 9228 (15.9)
L00-L99 Diseases o he skin and subcu aneous issue 1335 (20.5) 510 (31.8) 220 (37.2) 5717 (9.8)
F00-F99 Men al and beha iou al diso de s 1595 (24.4) 609 (38.0) 270 (45.6) 4663 (8.0)
I00-I99 Diseases o he ci cula o y sys em 1129 (17.3) 403 (25.1) 168 (28.4) 4902 (8.4)
A00-B99 Ce ain in ec ious and pa asi ic diseases 1102 (16.9) 425 (26.5) 228 (38.5) 4827 (8.3)
H00-H59 Diseases o he eye and adnexa 868 (13.3) 326 (20.3) 163 (27.5) 4056 (7.0)
H60-H95 Diseases o he ea and mas oid p ocess 909 (13.9) 315 (19.7) 153 (25.8) 3687 (6.3)
ICD-10 = In e na ional Classi ica ion o Diseases
FA s a us was de ined as he op decile o a ende s ( equen a ende 10%, FA10), p< 0.001 in all alues
1-yea -FA = Pa ien s ha we e in he op decile o a ende s in one o he s udy yea s (2014, 2015 o 2016)
2-yea -FA = Pa ien s ha we e in he op decile in any wo s udy yea s (2014, 2015 o 2016)
pFA = Pa ien s ha we e in he op decile in all h ee s udy yea s (2014, 2015 and 2016)
non-FA = Pa ien s ha we e ne e in he op decile we e conside ed as a e e ence g oup, non- equen a ende s
In he able a e p esen ed he 10 la ges ICD-10 g oups
Reho e al. BMC Public Heal h (2018) 18:1291 Page 7 o 9
o u he examine whe he hey a e also a isk o disabili y
and sickness absences. When planning u u e in e en ions
aimed a equen a ende s, he subg oup su e ing
om musculoskele al diso de s should be conside ed.
Among he wo king age pa ien s, iden i ied diso de s’
wo k- ela edness should be conside ed.
Abb e ia ions
CI: Con idence in e al; FA10: F equen a ende 10% (pa ien s in he op
decile o annual isi s o heal hca e p o essionals); GP: Gene al p ac ice;
MUPS: Medically unexplained physical symp oms; OH: Occupa ional heal h;
OHS: Occupa ional heal h se ices; OR: Odds a ios
Acknowledgemen s
The au ho s acknowledge he pa icipa ion o he occupa ional heal h s a
in he s udy and all he indi idual clien s who a e pa o his s udy.
Funding
This s udy is pa o he “E ec i eness and Indica o s o Occupa ional Heal h
Se ices”suppo ed by he Eu opean Social Fund [ e e ence numbe
S20659]. The unde had no ole in he design o he s udy no collec ion,
analysis, and in e p e a ion o da a o in w i ing he manusc ip .
A ailabili y o da a and ma e ials
The da a ha suppo he indings o his s udy a e a ailable om
Pihlajalinna Työ e eys bu es ic ions apply o he a ailabili y o hese da a,
which we e used unde license o he cu en s udy, and so a e no publicly
a ailable. Da a a e howe e a ailable om he au ho s upon easonable
eques and wi h pe mission o Pihlajalinna Työ e eys.
Au ho s’con ibu ions
The s udy was concep ualized by JU and he s udy design was planned by
all he au ho s. Planning o da a collec ion and analysis was done by all
au ho s. NT analyzed he da a. TR w o e he i s d a and all au ho s
con ibu ed o he inal e sion by e ising and commen ing on he d a . All
au ho s app o ed he inal e sion.
E hics app o al and consen o pa icipa e
The e hics commi ee o Pi kanmaa Hospi al Dis ic (ETL R16041) and he
Na ional Ins i u e o Heal h and Wel a e (THL/556/5.05.OO/2016) app o ed
he s udy. Based on Finnish legisla ion (Pe sonal Da a Ac , Finland, 22.4.1999)
indi idual consen is unnecessa y since no indi idual could be iden i ied due
o he size o he s udy popula ion.
Consen o publica ion
No applicable.
Compe ing in e es s
The au ho s’decla e ha hey ha e no compe ing in e es s.
Publishe ’sNo e
Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in
published maps and ins i u ional a ilia ions.
Table 4 Fac o s associa ed wi h equen a endance in mul inomial logis ic eg ession (n = 66,831)
1-yea -FA (2014–2016) 2-yea -FA (2014–2016) pFA (2014–2016)
Fac o nOR 95% CI nOR 95% CI nOR 95% CI
P o essionals isi ed
Physician 6513 1603 592
Nu se 4119 3.43 3.25–3.63 1192 5.39 4.80–6.06 460 6.19 5.07–7.56
Physio he apis 2932 4.73 4.48–5.00 1023 9.59 8.62–10.7 425 13.15 10.95–15.79
Psychologis 1174 6.19 5.71–6.70 467 11.92 10.6–13.5 196 14.44 11.99–17.40
Specialis consul a ion 1851 3.40 3.20–3.62 709 7.61 6.84–8.47 348 14.64 12.31–17.40
ICD-10
M00-M99 Diseases o he musculoskele al sys em and
connec i e issue
4796 4.59 4.33–4.86 1422 12.58 10.8–14.7 559 26.85 18.9–38.2
J00-J99 Diseases o he espi a o y sys em 4254 2.88 2.73–3.05 1321 7.50 6.57–8.55 536 15.55 11.79–20.52
R00-R99 Symp oms, signs and abno mal clinical and
labo a o y indings, no elsewhe e classi ied
2309 2.91 2.75–3.08 857 6.13 5.55–6.79 401 11.15 9.36–13.29
S00-T98 Inju y, poisoning and ce ain o he consequences
o ex e nal causes
2198 2.87 2.71–3.03 792 5.68 5.13–6.30 349 8.58 7.25–10.15
F00-F99 Men al and beha iou al diso de s 1595 3.67 3.44–3.92 609 7.05 6.33–7.85 270 9.68 8.19–11.44
L00-L99 Diseases o he skin and subcu aneous issue 1335 2.32 2.17–2.48 510 4.15 3.72–4.63 220 5.21 4.39–6.18
A00-B99 Ce ain in ec ious and pa asi ic diseases 1102 2.37 2.21–2.55 425 4.34 3.86–4.88 228 7.70 6.49–9.13
I00-I99 Diseases o he ci cula o y sys em 1129 2.13 1.98–2.29 403 3.38 2.99–3.81 168 4.00 3.32–4.83
G00-G99 Diseases o he ne ous sys em 976 3.03 2.80–3.27 403 5.69 5.05–6.42 220 10.00 8.41–11.89
K00-K93 Diseases o he diges i e sys em 934 2.60 2.40–2.81 379 4.75 4.20–5.36 202 7.93 6.65–9.44
ICD-10 = In e na ional Classi ica ion o Diseases
OR = Odds a io (adjus ed by sex, age, company size and ield o indus y), CI = Con idence in e al
1.0 = e e ence g oup (non-FA = non- equen a ende s, pa ien s ha we e ne e in he op decile we e conside ed as a e e ence g oup)
FA s a us was de ined as he op decile o a ende s ( equen a ende 10%, FA10),
1-yea -FA = Pa ien s ha we e in he op decile o a ende s in one o he s udy yea s (2014, 2015 o 2016)
2-yea -FA = Pa ien s ha we e in he op decile in any wo s udy yea s (2014, 2015 o 2016)
pFA = Pa ien s ha we e in he op decile in all h ee s udy yea s (2014, 2015 and 2016)
In he able a e p esen ed he 10 la ges ICD-10 g oups
Reho e al. BMC Public Heal h (2018) 18:1291 Page 8 o 9
Au ho de ails
1
Facul y o Medicine and Li e Sciences, Uni e si y o Tampe e, PB 100,
FI-33014 Tampe e, Finland.
2
Pihlajalinna Työ e eys, Tampe e, Finland.
3
Depa men o Public Heal h Sciences, Ka olinska Ins i u e , S ockholm,
Sweden.
4
Finnish Ins i u e o Occupa ional Heal h, Tampe e, Finland.
5
Clinic
o Occupa ional Medicine, Tampe e Uni e si y Hospi al, Tampe e, Finland.
Recei ed: 23 Feb ua y 2018 Accep ed: 14 No embe 2018
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