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Columbia march 2015

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Health in Swedish Children

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Columbia march 2015

  1. 1. Why are Swedish Children so Healthy? Jonas F Ludvigsson
  2. 2. Short about myself • Jonas (F) Ludvigsson • President, Swe Soc Pediatrics • Pediatrician/professor 50/50 • Football, guidebooks, Tintin • Three boys • Hannes, Elias and Josef (”HEJ”)
  3. 3. Sweden is not so big
  4. 4. Sweden is slightly different
  5. 5. 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)
  6. 6. 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)
  7. 7. Exclusive breastfeeding 0 20 40 60 80 100 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008 Procent Födelseår 2 mån 4 mån 6 mån
  8. 8. 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 society And no, we are not commies
  9. 9. Now, the background • 20% of inhabitants were born abroad/ foreign-born parents Only an isolated forested peninsula? • Other nordic countries • Somalia • Iraq • Balkan
  10. 10. ”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%
  11. 11. 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.
  12. 12. 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.
  13. 13. 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 change 0% 1,5% 3% 4,5% 6% IUGR Preterm birth
  14. 14. 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
  15. 15. Infections • Main cause of day to day morbidity • Emergency department: Night shifts: 54% infections [n=164] • Gastroenteritis and obstructive bronchitis dominate (RS virus)
  16. 16. Allergy/Asthma • Asthma/asthma like symptoms: 20% first 2 years, but fewer thereafter • 20% have eczema
  17. 17. ADHD • 3-5% • Increase in awareness • 1% gave other neuropsychiatric disorders; Asperger, autism, etc.
  18. 18. Psychiatric epidemiology
  19. 19. 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
  20. 20. Smoking • Average: 13% • Young men - smokeless tobacco • 4-month-old: 10% 0 7,5 15 22,5 30 High-income Low-income
  21. 21. Alcohol and drugs • Alcohol use in young people - European average • Drug users low (in adult group <0.2%)
  22. 22. 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
  23. 23. 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
  24. 24. Socioeconomy • Single mothers, low socioeconomic groups more accidents • Poorer dental health • Excess risk of stllbirth and early infant death
  25. 25. Swedish Health Systems • Human dignity [equal entitlement to dignity] • Need and solidarity (those with greatest need) • Cost-effectiveness
  26. 26. OrganizationFigure 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Local databases • Incompatible • process of buying new versions • Different registers • Quality registers
  31. 31. 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
  32. 32. Patient pathways • Medical care guarantee: all elective care • 0-7-90-90 rule [instant contact, family physician 7 days, specialist <=90 days,
  33. 33. 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
  34. 34. Immunization scheme • Only childhood vacations • school-leaving 14-16 years
  35. 35. Outpatient care • emergency care • planned consultation • day care • day surgery • home-based health care
  36. 36. 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
  37. 37. 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,
  38. 38. 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)
  39. 39. 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…]
  40. 40. Safeguarding/child abuse • 1979 Law • Mandatory reporting (all professionals: pre- school, schools, community services, health services) - if suspicion. • Rather low frequency, but reporting issues
  41. 41. Vulnerable populations • Asylum seekers/hidden refugees: children same rights • Law: those in greatest need take priority
  42. 42. And what about salaries? • Pediatrician in training 4500 USD/month • Specialist: 5500 USD • Senior consultant: 6500 USD • Professor and senior consultant: 7500 USD
  43. 43. The End jonasludvigsson@yahoo.com Look, no ”dot”

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