Bertil: Care of myocardial infarction: Sweden excels.
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The development of new evidence based diagnostic methods, drugs, interventions and medical devices in the cardiovascular field in general, and in acute myocardial infarction (AMI) in particular, has been dramatic the last 30 years. During the same period a substantial decrease in the mortality after AMI has been noted in most western countries, including Sweden1. This could partly be explained by the adoption of new and better diagnostic methods and treatments2, 3. Attributes of the care system, such as organisational culture (e.g. flexibility and willingness to change), care pathways and type of financial incentives play an important role for the adoption of new methods and therapies. However, changes in risk factor patterns in the general population seem equally important for explaining the decrease in mortality3. Thus, these facts emphasize the importance of a comprehensive strategy that promotes development and implementation of evidence-based medical methods and treatment measures as well as measures to improve public health (primary prevention). It also means that outcome measures such as mortality after AMI, do not only reflect the performance of the health care system but also reflect the general public health.

In international comparisons of care, the results of Swedish care for AMI usually ranks among the best; Sweden together with Denmark had the lowest in-hospital mortality after AMI (year 2007) among 8 OECD countries, including United States and the UK4. In a recent unique study comparing the short-term outcome after AMI in Sweden and the UK, the crude 30-day mortality was 7.6 % in Sweden and 10.5 in the UK5. In an attempt to isolate the effect of differences in the health care, case-mix adjustments were made for a long list of background factors. After adjustment, the shortterm mortality rate was still 37% higher in the UK, corresponding to more than 11,000 excess deaths. Furthermore, significant differences in the use of evidence-based treatments between the two countries were found. The authors suggested that the difference in outcome is due largely to the divergent speed of implementation of policy initiatives to improve care.

Against this background, I will briefly discuss a few issues characterizing the Swedish cardiac care. In order to have good results on a national level, the care must be available for all inhabitants. Equal access to care regardless of socioeconomic status is a corner stone in the Swedish health care system. Despite that, there are still differences in the uptake of secondary prevention measures after AMI, e.g. use of ACE-inhibitors are lower in those with lower income6.

There has been a rapid decrease in regional variation in the acute care of AMI in Sweden over the last 10-15 years; today the regional variations are relatively small with a homogeneous uptake of evidence based therapies7. The reasons for this positive development are clearly multifactorial. One factor is the nationwide quality registries, strongly founded in the professions. The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) measures both processes and results, with transparent and public reporting of the results on hospital level8. The public reporting has highlighted the regional differences and created a positive competition within the professions and among the care givers to provide the best care9.

In order to even further stimulate development of the health care in Sweden there is a ranking between hospitals performed by the independent news magazine for health care, Dagens Medicin. In this yearly ranking, registry and enquiry data about quality of care (treatment targets), patient safety, implementation of evidence-based methods, cost effectiveness and patient satisfaction are aggregated. For cardiac care among university hospitals the Heart Centre in Umeå has achieved the top ranking the last two years giving their staff positive feed-back to carry on and the other university hospitals incentives and targets to improve.

During the last two decades the international quality improvement movement has influenced the Swedish health care system, providing new insights in the science of quality improvement and providing tools for the application in clinical practice. Quality improvement methods have successfully been used to improve the AMI care in Sweden10.

The Swedish guidelines for cardiac care from The National Board of Health and Welfare provide an evidence-base for different treatments and simultaneously prioritize the treatments based on the severity of the underlying disease state and the effectiveness (including cost effectiveness) of the treatment11. The guidelines have created a pressure on all care-givers to provide the top prioritized treatments and diagnostic procedures; and to measure the implementation of these treatments and procedures. Finally, the strong tradition of wide spread participation in clinical research have played a role, e.g. for the rapid general uptake of an invasive strategy in non-ST-elevation acute coronary syndromes12, and new antiplatelet agents13.

The Swedish health care system, together with most of the western world, faces many challenges in the future. The rapid increase in fundamental biological knowledge and the technological development cause an increasing gap between what we can do (diagnostically and therapeutically) and the available resources; and create a strong pressure to prioritize measures that maximize the value (effect in relation to cost) for the patients. Therefore, it is fundamental to have well trained physicians and nurses and to secure that they are able to constantly up-date their knowledge and skills, implement new evidence based treatments and procedures and remove old obsolete methods. It is also fundamental that the whole healthcare system participates in generation of new knowledge and innovations; clinical research must be part of the core business of the health care system. The decreasing participation in clinical trials seen in Sweden over the last 10-15 years are therefore worrisome. The care givers must optimize the way care is delivered, which might imply that some care must be more disseminated in order to achieve widespread access, and other very specialized care must be more concentrated to few places in order to secure the highest quality and cost-effectiveness.

However, to continue the successful lowering of the incidence of ischemic heart disease as well as mortality after AMI, measures on a societal level to promote a healthier life style must continue, such as further decrease the use of tobacco, lower the intake of sugar and other unhealthy food, and increase of regular physical activity. The real challenge is to reach all parts of the society, also to those with less capability or less motivation to change their life-style. The tremendous success of the last 30 years is encouraging, let us work together so that the next 30 years will be equally successful in the battle against coronary artery disease and other heart diseases.

No conflict of interest to declare in relation to this topic

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Copyright (c) 2015 Bertil Lindahl

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