columbia march 2015
TRANSCRIPT
Why are Swedish Children so Healthy?
Jonas F Ludvigsson
Short about myself• Jonas (F) Ludvigsson
• President, Swe Soc Pediatrics
• Pediatrician/professor 50/50
• Football, guidebooks, Tintin
• Three boys
• Hannes, Elias and Josef (”HEJ”)
Sweden is not so big
Sweden is slightly different
More stats on health• Not been to war since 1812
• 10 million people (17%; 0-14 years)
• (otherwise a very old population)
0
1,25
2,5
3,75
5
Perinatal mortality Neonatal mortality Infant mortality Maternal mortality
(Blue=maternal data)
More stats on health (2)
0
25
50
75
100
Teenage pregnancy Immunization Measles
1.4%
97.4%
11.8%
91% [and dropping]
(Yellow=Sweden. Blue=US)
Exclusive breastfeeding
0
20
40
60
80
100
1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008
Procent
Födelseår2 mån 4 mån 6 mån
Key message• Low corruption
• Stable economy allowing for reforms
• Free compulsory school [literacy rate 99%]
• Pre-school for everyone
• Low socioeconomic gradients
• High pediatric competence, also in outpatient settings
• Preventive maternity ward and child health care
• Preventive focus throughout societyAnd no,
we are not commies
Now, the background
• 20% of inhabitants were born abroad/foreign-born parents
Only an isolated forested peninsula?
• Other nordic countries
• Somalia
• Iraq
• Balkan
”The economy, stupid”
• Strong growth in 1950s, 60s, 70s
• Crash in the 1990s
• Surplus required by law
• Government debt
Apologies for any political connotations
0%10%20%30%40%50%60%70%80%
2000 2009
38%
69%
Financial support to children• Child allowance (”Barnbidrag): 125 USD/month
• Supplementary allowance for families >2 children
• Parental leave: 390 days per child: 80% of the income up to about 50-60,000 USD/year
• Extra days with lower compensation
• Parental leave. 2 months/father [one parent]
• Day care, subsidised [100 USD/month]. 80% of childen before 2 years of age.
The primary care sector• Average hospital: 2 peds wards: neonatal+older
• Subspecialisation: In my hospital usually two gastro, 2 nephologists, 3-4 allergy, 1 obesity, 2 infectious disease/cystic fibrosis etc.
• General practitioners: 3 months paediatrics
• Ambulatory care centres: secondary care level close to families.
First year of life• Neonatal and infant mortality have decreased
• Still, mortality in first year > than 1-15 years combined
• Preterm birth and low birth weight
• Mortality first week down
• Stillbirth no change0%
1,5%
3%
4,5%
6%
IUGR Preterm birth
Road traffic mortality
0-17 years of age
Preventive focus, largely explains the low child mortality
16/ 100000
3.8/ 100000
UK: 6
Safety seats in cars, developed in Swe cars in 1960
Infections
• Main cause of day to day morbidity
• Emergency department: Night shifts: 54% infections [n=164]
• Gastroenteritis and obstructive bronchitis dominate (RS virus)
Allergy/Asthma
• Asthma/asthma like symptoms: 20% first 2 years, but fewer thereafter
• 20% have eczema
ADHD
• 3-5%
• Increase in awareness
• 1% gave other neuropsychiatric disorders; Asperger, autism, etc.
Psychiatric epidemiology
Other chronic diseases• Type 1 diabetes: 0.7% [highest after Finland] -
almost no Type 2 diabetes
• Obesity [3-5%], doubled but stabilised (and decreased).
Less candy and soft drinks
More fruit and vegetables
Smoking
• Average: 13%
• Young men - smokeless tobacco
• 4-month-old: 10%0
7,5
15
22,5
30
High-income Low-income
Alcohol and drugs
• Alcohol use in young people - European average
• Drug users low (in adult group <0.2%)
Sexual health
• Women aged 15-24 years: 80% use contraceptives
• 1/4 pregnancies in Sweden end in abortion. Stable abortion rates since 1970s. 90% of abortions carried out before 12 weeks of pregnancy
Anti-spanking
• 1979: forbidden to hit your child
• in 2006: 7% of Swedish parents were positive about corporal punishment
• Number of children reporting physical punishment have decreased rapidly
Socioeconomy
• Single mothers, low socioeconomic groups more accidents
• Poorer dental health
• Excess risk of stllbirth and early infant death
Swedish Health Systems
• Human dignity [equal entitlement to dignity]
• Need and solidarity (those with greatest need)
• Cost-effectiveness
Organization
6
Figure 3.1 Overview of the organisation
Parliament
National!government
Ministry(of(Health(and$Social$Affairs
15#government#agencies(involved(
in#health
290$municipalities
Public'and'private'services'(special'housing(and(home(care)!for$elderly$and$
disabled
Seven%university%hospitals
Approximately-70-county'council'
operated(hospitals(and(six$private$hospitals$
Approximately-1100-public'and'private'care'
facilities
Public'and'private'dentists
21#county#councils
Approximately-1200-private(pharmacies(
SALAR
Primary care
• 1100 primary care units in Sweden
• No gate-keeping function
• six medical care regions
• Often the local authorities introduce reforms!: a) primary health care + b) coordination of care of older people
Patient information
• National barometers - what does the patient think about his/her care?
• SALAR/SKL collects data and compiles
• 1177 (web site and phone): written by medical staff and pharmaceuticals. Open 24/7.
• omvard.se
Patient choice• Gradually since 1990s
• Payment for providers follow the patients
• In all county councils except Sthlm: passive registration
• Payment: global budgets, case-based, performance-based [patient not pay more than 110 USD during a 12-month visit]. Children free of charge.
• City council pays all inpatient drugs
• City council pay all expenses above 300 USD for medication
Local databases
• Incompatible
• process of buying new versions
• Different registers
• Quality registers
Quality of professionals• Licenses
• malpractice (HSAN)
• Medical education financed by the state (free)
• Physician: 5.5 years + 21 months training + written examination. Another 5 years —> paediatrician
• 12-1300 children per paediatrician
Patient pathways
• Medical care guarantee: all elective care
• 0-7-90-90 rule [instant contact, family physician 7 days, specialist <=90 days,
Asthma- what happens• Not an emergency or the child < 2 yard
• visit family physician
• follow-up appointment in 7 days
• family physician will diagnose and treat and follow-up
• If severe asthma, referred to ambulatory/Peds dept
Immunization scheme
• Only childhood vacations
• school-leaving 14-16 years
Outpatient care
• emergency care
• planned consultation
• day care
• day surgery
• home-based health care
Neonatal specialisation
• 4-5 hospitals, neonates <28 gestational weeks
• Pediatric neurosurgery/cancer, centralised
• surgery congenital heart disease - 2 centres
• Rare disorders inborn error of metabolism; liver transplantation
Emergency care• 7 university hospitals + 2/3 all county council
hospitals
• open 24/7
• special nurses (3 years of training)
• Meningococcal infection: referred to emergency care, transport with ambulance, perhaps intensive care unit,
Rehabilitation• child and adolescent rehabilitation
• specialised nurse, psychologist, physiotherapist, speech therapist, social workers
• Aim: participate in daily activities, support parents, ensure the family can participate in community activities
• Special schooling (but often normal school with assistant)
Adolescence/youth clinics
• Teenage
• started in the 1990s
• educate parents (lectures of 1-week courses for physicians)
• http://www.umo.se [even a panic button to leave the site…]
Safeguarding/child abuse
• 1979 Law
• Mandatory reporting (all professionals: pre-school, schools, community services, health services) - if suspicion.
• Rather low frequency, but reporting issues
Vulnerable populations
• Asylum seekers/hidden refugees: children same rights
• Law: those in greatest need take priority
And what about salaries?
• Pediatrician in training 4500 USD/month
• Specialist: 5500 USD
• Senior consultant: 6500 USD
• Professor and senior consultant: 7500 USD
