title: [Regulations of sickness certification as a factor for increased health care utilization in Germany].
abstract: BACKGROUND
  In Germany, utilization of ambulatory health care is high compared to other countries. Classical models of health care utilization cannot sufficiently explain these differences. The aim of this study was to explore relevant factors which can explain the higher health care utilization in Germany. In this article, we focus on regulations regarding sickness certification as a potential factor.
  
  
  METHODS
  An explorative qualitative study design. We conducted episodic interviews with 20 patients in Germany and 20 patients in Norway and participant observation in four primary care practices each. Additionally, we conducted a context analysis of relevant health care system related factors which emerged during the study. Qualitative data analysis was done by thematic coding in the framework of grounded theory.
  
  
  RESULTS
  The need for a sickness certificate was an important reason for encounter in Germany, especially regarding minor illnesses. Sickness certification is a societal topic. GPs play a double role regarding sickness certification, both as the patients' advocate and as an expert witness for social security services. In Norway, longer periods of self-administered sickness certification and more differentiated possibilities of sickness certification have been introduced successfully.
  
  
  CONCLUSIONS
  Our results point to regulations regarding sickness certification as a relevant factor for higher health care utilization in Germany. In pilot studies, the effect of extended self-certification of sickness and part-time sickness certification should be further assessed.
authors.affiliation: Otto-von-Guericke-Universität Magdeburg, Institut für Allgemeinmedizin, Magdeburg, Deutschland; Charité-Universitätsmedizin Berlin, Institut für Allgemeinmedizin, Berlin, Deutschland. Electronic address: wolfram.herrmann@charite.de.
authors.forename: Wolfram J
authors.initials: WJ
authors.lastname: Herrmann
authors.affiliation: Otto-von-Guericke-Universität Magdeburg, Institut für Allgemeinmedizin, Magdeburg, Deutschland; Charité-Universitätsmedizin Berlin, Institut für Allgemeinmedizin, Berlin, Deutschland.
authors.forename: Alexander
authors.initials: A
authors.lastname: Haarmann
authors.affiliation: University of Bergen, Department of Global Public Health and Primary Care, Bergen, Norwegen.
authors.forename: Anders
authors.initials: A
authors.lastname: Bærheim
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003431:Cross-Cultural Comparison; D004185:Disability Evaluation; D004608:Eligibility Determination / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D005104:Expert Testimony / Q000331:legislation & jurisprudence; D005260:Female; D058006:General Practice / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D005858:Germany; D006801:Humans; D008297:Male; D000069342:Medical Overuse / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D008875:Middle Aged; D009664:Norway; D010819:Physician's Role; D036301:Qualitative Research; D012017:Referral and Consultation / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D018582:Sick Leave / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data*; D014600:Utilization Review; D055815:Young Adult
keywords: Arbeitsunfähigkeit; Deutschland; Germany; Inanspruchnahme; Norway; Norwegen; Qualitative Forschung; Sickness certification; general practice; hausärztliche Versorgung; health care utilization; qualitative research; sick note