Björn Smedby

Cost containment, solidarity and cautious experimentation : Swedish dilemmas

This paper uses secondary data analysis and a literature review to explore a Swedish Dilemma: Can Sweden continue to provide a high level of comprehensive health services for all regardless of ability to pay--a policy emphasizing solidarity--or must it decide to impose increasing constraints on health services spending and service delivery--a policy emphasizing cost containment? It examines recent policies and longer term trends including: changes in health personnel and facilities; integration of health and social services for older persons; introduction of competition among providers; cost sharing for patients; dismantling of dental insurance; decentralization of government responsibility; priority settings for treatment; and encouragement of the private sector. It is apparent that the Swedes have had considerable success in attaining cost containment--not primarily through market mechanisms but through government budget controls and service reduction. Further, it appears that equal access to care, or solidarity, may be adversely affected by some of the system changes.

HOSPITAL CASELOADS IN LIVERPOOL, NEW ENGLAND, AND UPPSALA: An International Comparison

Abstract An international comparative study has been made of the annual caseload of short-stay hospitals in the Liverpool hospital region, the Uppsala hospital region (Sweden), and New England (U.S.A.). This is the first such population-centered collaborative international study. Psychiatric and obstetric patients have been excluded, as have special-care babies. The Liverpool region discharges fewer patients than the other two regions, despite having more discharges of adults than any other hospital region in England and Wales; the deficiency is in adults. The New England rate of operations performed is considerably higher than in the other two regions. Uppsala and Liverpool have similar rates except that Uppsala has significantly more gallbladder and gynaecological operations.

Perception of and Response to Symptoms of Illness in Sweden and the United States

ences in patterns of use of physicians and hospitals in Sweden and in the United States. The mean number of physician visits per person per year is about five in the U.S. and three in Sweden. Although both Sweden and the U.S. have approximately 130 admissions per 1000 population to short-term hospitals per year, the average length of stay is 13 days in Sweden compared with eight days in the U.S.15 Various reasons, including different levels of illness, contrasting methods of organizing and supplying health services, and varying perceptions of and responses to illness, could account for such differences. This paper will be concerned with the influence of perception and response on physicianuse patterns. Do people in Sweden and

Prescription Drug and Healthcare Use Among Swedish Patients Treated with Antidepressants

Objective: To analyze healthcare and prescription drug use among patients taking and those not taking antidepressant drugs in a Swedish community. Design: Cross-sectional study. Setting: General population of the rural Swedish municipality Tierp of approximately 20 000 inhabitants. Participants: All residents of Tierp aged 25 years or older during 1988. Main Outcome Measures: Mean number of ambulatory care visits, hospital bed days, and prescriptions per person; proportion of those taking prescription drugs in different pharmacologic classes. Results: Patients treated with antidepressant drugs had a significantly (p < 0.05) greater use of ambulatory care, hospital care, and prescription drugs than those who did not take antidepressants in the study population. They also had an increased frequency of use of prescription drugs from virtually all pharmacologic classes. Furthermore, the risk for polypharmacy was high in patients treated with antidepressant medications. Conclusions: Those who took antidepressant drugs consumed more health services and prescription drugs than did those not taking an antidepressant. Patients receiving antidepressant treatment may be at serious risk for iatrogenic disease and should be evaluated carefully with respect to concomitant drug use.

What is value for money in medical care? Experiences in England and Wales, Sweden, and the U. S. A.

Abstract England and Wales, the United States, and Sweden are all healthy, affluent, industrial countries; but the development of their health services has led to striking differences in the provision of medical care and the use made of it. A review of published data on health, expenditure, staffing, and use of services by the patient highlights some of these differences and indicates that in certain instances there are insufficient facts available for decisions on the best use of necessarily inadequate resources to be made. Mortality in the three countries is essentially similar. In the United States expenditure on the health services as a percentage of the gross national product is rising, as it is in Sweden; but in England and Wales relative expenditure on the National Health Service has been stable. The three countries are widely different in their attitudes to the concept of the personal (family) doctor, but the consequences of this are not known. The same is true for differences in frequency of patient-doctor contacts. Details of personal and disease characteristics of inpatients are available so far for England and Wales only. In England and Wales admission-rates are lower but length of stay longer than in Sweden or the United States. Details for the input of the health services (expenditure, numbers of beds, staff, buildings) are readily available: more information is required for morbidity-rates and patient-demand, and some information on the outcome, before the true effects of the different systems for producing medical care can be understood.

Psychiatric Symptoms and Psychosocial Problems in Primary Health Care as Seen by Doctors

All visits at a primary health care centre in Sweden were studied during four weeks. The frequency of psychiatric symptoms or psychosocial problems noted by the doctors was recorded on a special form in addition to routine registration of diagnoses. Such problems were noted in 553 out of 3 205 visits, corresponding to 17.3%. Considerable variation in registering problems was found between individual physicians and between different categories of doctors. The most common problems were nervousness, anxiety, psychosomatic disorders, and depression. Mental problems were especially common in connection with gastritis, precordial pain, and abdominal pain. There was a difference between the sexes: 20% of the female patients had mental problems registered compared with 14% of the male patients. Psychiatric diagnoses, however, were registered in only 6% of all cases. Of the 553 patients with mental problems, 16% were considered in need of a specialist, 52% could be dealt with at the health centre, and for 32% no special treatment for the mental problems was regarded necessary. One conclusion is that the routine registration of diagnoses at the health centre covers only some of the mental problems and is therefore insufficient in terms of planning psychiatric resources and the training of doctors. Possible reasons for the differences found are discussed.

Psychotropic drug use in a Swedish community—Patterns of individual use during 2 years

Psychotropic drug use in a Swedish community with a general population of about 20,000 was studied using data from a research registry on prescriptions. Patterns of individual psychotropic drug use during 2 years, 1980 and 1981, were analyzed. Use during the second year was studied in relation to use during the first year, and individuals with continued and new use were identified. About two thirds of those who obtained psychotropics during the first year continued using such drugs during the following year. Among those with no use during the first year, 6% obtained psychotropic drugs during the second year. Both continued and new use increased with age. Psychotropic drug use was nearly twice as common among women as compared to men among new users, whereas practically no sex difference was observed in continued use among previous users of psychotropics. Despite the finding that male psychotropic drug users were almost as likely as females to continue using these drugs, the overall proportion of continuous users in the population remained considerably higher among women as compared to men. The results from this study suggest that the greater use of psychotropics among women can be explained by a greater extent of occasional use as well as continuous use among women as compared to men.

Defining Heavy Use of Prescription Drugs A Methodological Study

Many studies showed that a small proportion of those using health care account for a large proportion of the total care consumed. These studies had different goals, used various designs and definitions of the heavy user, examined different types of use, and used different units of measurement. Common to all of them was an effort to define and study the heaviest users of care. In some studies the heavy user was defined according to arbitrarily chosen fixed limits. In studies on heavy use of ambulatory care, hospital care, and use of medical drugs, individuals whose use exceeded a certain number of physician visits, a certain

What is value for money in médical care? Experiences in England and Wales, Sweden, and the U.S.A

Abstract England and Wales, the United States, and Sweden are all healthy, affluent, industrial countries; but the development of their health services has led to striking differences in the provision of medical care and the use made of it. A review of published data on health, expenditure, staffing, and use of services by the patient highlights some of these differences and indicates that in certain instances there are insufficient facts available for decisions on the best use of necessarily inadequate resources to be made. Mortality in the three countries is essentially similar. In the United States expenditure on the health services as a percentage of the gross national product is rising, as it is in Sweden; but in England and Wales relative expenditure on the National Health Service has been stable. The three countries are widely different in their attitudes to the concept of the personal (family) doctor, but the consequences of this are not known. The same is true for differences in frequency of patient-doctor contacts. Details of personal and disease characteristics of inpatients are available so far for England and Wales only. In England and Wales admission-rates are lower but length of stay longer than in Sweden or the United States. Details for the input of the health services (expenditure, numbers of beds, staff, buildings) are readily available: more information is required for morbidity-rates and patient-demand, and some information on the outcome, before the true effects of the different systems for producing medical care can be understood.

FORMAL AND INFORMAL SUPPORT AMONG ELDERLY IN A RURAL SETTING IN SWEDEN

More detailed knowledge is needed in Sweden about how the service and care needs of elders are met and to what extent the help is provided as formal or informal support. A study of elders (75+) liv ...