Respirology | 2021
Letter from Sweden
Abstract
In Sweden, physicians have faced major changes in their working conditions over the past three to four decades. Sweden is now ranked second or third among the 27 EU countries with the lowest number of hospital beds in relation to the population size. Regarding respiratory medicine, departments are now fewer in number and smaller than previously, and in most hospitals they are small sections within departments of internal medicine. Above that, for some decades, the ruling system of public health care has followed the ideas of ‘new public management’, which has resulted in an increased bureaucracy parallel to working conditions somewhat resembling industrial assembly lines. Parallel to these changes, the healthcare system in Sweden has faced an increased privatization both of primary and specialist care. Related or unrelated to this, it is noted that the relative proportion of original scientific articles from Sweden in international peer-reviewed journals has decreased, which is also true for respiratory medicine. The decrease in Swedish impact on research of respiratory diseases, and of the Scandinavian countries as well, is reflected by the history of the European scientific journals within the field of respiratory medicine. The Scandinavian Journal of Respiratory Diseases was highly reputable 40 years ago. It merged with the Belgian journal Acta Tuberculosea et Pneumologica Belgica in 1985 to form the European Journal of Respiratory Diseases (the precursor of the modern European Respiratory Journal), with its first editors being Erik Berglund from Sweden and Jean-Claude Yernault from Belgium. The development of the journals is not bad in itself, but it reflects changes in the impact of Sweden and Scandinavia in Europe. Scandinavia and Sweden have a strong focus on epidemiology. Two recent large-scale population studies on respiratory health, the West Sweden Asthma Study (WSAS) in the south-west and Obstructive Lung Disease in Northern Sweden (OLIN), indicate the prevalence of asthma is still increasing in Sweden, although the increase seems to be levelling off. The prevalence of adult asthma is today about 10%, slightly higher than found in 2008 in the Swedish part of the GA(2)LEN collaboration in four centres in different parts of the country. With the introduction of biologics, severe asthma has become a greater focus, with a prevalence estimated at 0.5–1% of the general adult population in Sweden. Collaboration of research and management of severe asthma is in progress with researchers and physicians in the Nordic countries, as well as within the European Respiratory Society and the European Academy of Allergy and Clinical Immunology. Specialist units for management of severe asthma, and for guidance of other units, are under development in Sweden. Another major field of respiratory medicine, as in most countries, is chronic obstructive pulmonary disease (COPD). Primary care units are the main bodies for COPD patient care. This is in collaboration with lung departments at hospitals in case of exacerbations that need hospitalization or more complex care. There are only a few specialized units for COPD management in Sweden, with the leading one in the second largest city of Gothenburg. As in all European countries, there is considerable under-diagnosis of COPD. Reasons are the same as in most other countries, that is, lack of use of spirometry in primary care in combination with the slow progress of disease in the majority of cases. However, nation-wide standard-of-care programmes are being developed for multiple common non-communicable diseases including COPD, which might importantly improve the rate of a correct (!) diagnosis. Interestingly, it was recently shown that after decades of decreases in smoking, the prevalence of COPD has finally started after the millennium shift to go down. COPD prevalence was recently estimated at 8.6% in people aged ≥40 years in population-based studies using the fixed-ratio definition, and slightly lower when the lower limit of normal criteria of obstruction is applied. The decrease in prevalence is most pronounced for moderate to severe COPD. However, COPD mortality is still increasing among women, in contrast to men. Sweden is a country of registers coupled to the unique personal identifier number of each individual. There is a national patient register, a national cause of death register, a socioeconomic register and also multiple registries related to chronic diseases such as diabetes and heart failure. In 2013, the Swedish National Airway Registry started; nowadays, more than 1000 clinics are participating from both primary and secondary care with registered data on 205,833 patients with asthma and 80,372 with COPD. The aim of the registry is to improve the care for people with airway disease by providing the key indicators for follow-up, direct feedback to registering units and creating new possibilities for research questions. Several researchers are involved in international cooperative projects. For example, both the GA(2)LEN and Received: 9 March 2021 Accepted: 10 March 2021