Injury mortality in Sweden; changes over time and the effect of age and injury mechanism

Background: Injuries are one of the most common causes of death in the world. Varying types of injuries dominate in different parts of the world, which also have separate influences mortality. In Scandinavia blunt injuries dominates and the majority of those who die do so pre hospital. Over time different injury pattern may vary and by analyzing this we can assess when, where and how preventive work can be reinforced. The aim of this thesis was to study injury epidemiology in Sweden and assess the contribution of different injury patters on mortality. Method: We used the Swedish cause of death and the national patient registries which have a complete national coverage. ICISS was calculated (based on ICD-10) in the in hospital population. We have chosen to do this investigation with a broad perspective using the term injury, which includes trauma but also other diagnoses like suffocation and drowning. Results: During the study period (1999-2012) the number of deaths because of injury was 1213, 25 388, and 18 332 among children, working age and elderly, respectively. Mortality declined in the children and in the working age but inclined in the elderly. Mortality increased with each age group except between the ages of 15–25 and 26–35 years. One thousand two hundred sixty four (97%) of those who died because of penetrating trauma (sharp objects and firearms) were killed by intentional trauma (assault and intentional self-harm). One thousand and seventeen (83%) of the children died prehospital. In the working age 22 211 (80%) of 25 388 died pre hospital. Nine thousand six hundred and eighteen (53%) of 18 332 of the elderly died prehospital. During 2001- 2011 the risk adjusted in hospital mortality decreased in traffic and assault but not in fall related injuries. Discussion: Largely, the anticipated injury mortality picture was found, with blunt injuries (traffic accidents) dominating in the working age and falls in elderly. Further a significant portion of the deaths occurred pre hospital. The intentional injuries are dominated by intentional selfharm. The decrease in child injury mortality is notable as Sweden already has one of the lowest incidences in child injury mortality in the world. The decrease in injury mortality in the working age also implies that preventive work has had an effect. The incline in injury mortality in elderly on the other hand needs to be further studied. Areas of particular importance for future preventive work is the incline in injury mortality in elderly and intentional injuries among children.

The reregulation of the Swedish pharmacy market : Goal fulfillment and a counterfactual analysis

Sveriges apoteksmarknad omreglerades år 2009 från ett statligt monopol till en konkurrensutsatt marknad. Orsaken till reformen var liberaliseringsinfluenser inom ekonomin från 90-talet, utifrån teori såväl som medlemskapet i Europeiska Unionen. Reformen mottogs med blandade känslor vilket reflekteras väl i de många motsägande utvärderingarna av reformen de efterföljande åren. Bristen av konsensus om målens uppfyllelse samt de många opartiska granskningarna leder till uppsatsens syfte att granska om målen med reformen är uppfyllda nu nio år senare eller ej. Målen med omregleringen presenteras i proposition 2008/09:145 och är övergripande: ökad tillgänglighet, förbättrad service och låga kostnader för konsumenter och staten. Metoden i uppsatsen är måluppfyllelseanalys med stöd i ett kontrafaktiskt scenario, Sverige utan omregleringen vilket baseras på en applikation av Finlands utveckling efter 2009. Analysen granskar målet utifrån nio aspekter och kommer fram till att marknaden med omreglering uppvisar bättre resultat i åtta av dem jämfört med resultatet på marknaden som inte omreglerades. Den omreglerade marknaden genererade 434 fler apotek och antalet ökade i nio utav tio områden med mellan 18,9 och 80,7 procent mer än den icke reglerade. Öppettiderna var även 11,2 timmar längre per vecka på den omreglerade marknaden. Totalt tillkom det 956 fler farmaceuter när marknaden omreglerades, antal apotek ökade dock snabbare och förhållandet mellan farmaceuter och apotek försämrades mer med omregleringen än utan. På den omreglerade marknaden gick det fem farmaceuter per apotek istället för sex, direktexpedieringen ökade dock med 1,6 procent mer. De totala kostnaderna ökade med 0,289 miljoner euro mindre och kostnaderna per person sjönk istället för att stiga, även priserna i detaljhandel föll mer med omregleringen än utan. Målet om ökad tillgänglighet och låga kostnader är således uppfyllt, målet om förbättrad service är uppfyllt till viss grad. Den totala bedömningen av omregleringen är att den varit lyckad. Sweden's pharmacy market underwent a reregulation year 2009 from a public monopoly to a market exposed to competition. The reason for the reform was liberalization influences in the economy during the nineties, in economic theory aswell as from becoming a member of the European Union. The reform was received with mixed feelings which was well reflected in the many contradictory assessment reports of the reregulation the following years. The lack of consensus about the goal fulfillment and the many impartial reviews leads to the purpose of this essay, to examine if the goals of the reform are fulfilled now nine years later or not. The goals of the reform are presented in proposition 2008/09:145 as following: increased accessibility, improved service and low costs for consumers and the government. The method is goal fulfillment with support in a counterfactual analysis, Sweden without reregulation, that is based upon Sweden before the reregulation with the application of Finland's development after 2009. The analyze examines the goal from nine aspects and lands in the fact that the market with reregulation shows a better result in eight out of nine of them compared with the result of the market without a reregulation. The reregulated market generated 434 more pharmacies and the number increased in nine out of ten areas with between 18,9 and 80,7 percent more than the non-reregulated market. The open hours were also 11,2 hours longer per week in the reregulated market. The total added number of pharmacist increased by 956 workers with the reregulation, however, the number of pharmacies increased at a greater rate and the relation between pharmacists and pharmacies worsened, more with the reregulation than without. On the reregulated market there were five pharmacists per pharmacy instead of six, however directly dispensed medicine increased with 1,6 percent more. Total governmental costs increased with 0,289 million euro less and the cost per person decreased instead of increased, also the prices in retail dropped more with the reregulation than without. The goal of increased accessibility and low costs are therefore fulfilled, the goal of improved service is fulfilled to a certain degree. The total assessment of the reregulation is that it has been successful.

A cohort study of trauma patients in Sweden during the first months of the COVID-19 pandemic : a small reduction in trauma admissions

Background Given that Swedish authorities have been widely viewed as having practiced an unusual approach to the COVID-19 pandemic and given that Sweden is notable for a low incidence of trauma, we wanted to learn how the pandemic may have affected the number of trauma admissions in Sweden. Methods We conducted a retrospective cohort study based on the Swedish trauma registry (Svenska Traumaregistret). The study period was March 1, 2020 to June 30, 2020. As a basis for comparison, the record for the same time during the previous year, 2019 was used. Results During the four months of the first wave of COVID-19, 2020 there was a decline of 24.2% in the total number of trauma patients in Sweden. There was no significant change in 30-day mortality rates, 4.7% 2019 and 5.1% 2020, (p = 0.30). The number of injuries per patient was higher during the pandemic 3.8 injuries 2019 and 4.1 injuries 2020 (p = 0.02). The NISS 6, 2019 and 8, 2020 was higher during the pandemic. Conclusions As a consequence of what were seen by many as all too lenient actions taken to deal with COVID-19 in Sweden during spring 2020, there was still a reduction in trauma admissions most likely due to an adherence to the voluntary recommendations, the reduction was not as prominent as what was seen in many countries with harsher restrictions and lockdowns.Funding Agencies|Linkoping University; Center for Disaster Medicine and Traumatology, Linkoping (KMC)</p

The reregulation of the Swedish pharmacy market : Goal fulfillment and a counterfactual analysis

Sveriges apoteksmarknad omreglerades år 2009 från ett statligt monopol till en konkurrensutsatt marknad. Orsaken till reformen var liberaliseringsinfluenser inom ekonomin från 90-talet, utifrån teori såväl som medlemskapet i Europeiska Unionen. Reformen mottogs med blandade känslor vilket reflekteras väl i de många motsägande utvärderingarna av reformen de efterföljande åren. Bristen av konsensus om målens uppfyllelse samt de många opartiska granskningarna leder till uppsatsens syfte att granska om målen med reformen är uppfyllda nu nio år senare eller ej. Målen med omregleringen presenteras i proposition 2008/09:145 och är övergripande: ökad tillgänglighet, förbättrad service och låga kostnader för konsumenter och staten. Metoden i uppsatsen är måluppfyllelseanalys med stöd i ett kontrafaktiskt scenario, Sverige utan omregleringen vilket baseras på en applikation av Finlands utveckling efter 2009. Analysen granskar målet utifrån nio aspekter och kommer fram till att marknaden med omreglering uppvisar bättre resultat i åtta av dem jämfört med resultatet på marknaden som inte omreglerades. Den omreglerade marknaden genererade 434 fler apotek och antalet ökade i nio utav tio områden med mellan 18,9 och 80,7 procent mer än den icke reglerade. Öppettiderna var även 11,2 timmar längre per vecka på den omreglerade marknaden. Totalt tillkom det 956 fler farmaceuter när marknaden omreglerades, antal apotek ökade dock snabbare och förhållandet mellan farmaceuter och apotek försämrades mer med omregleringen än utan. På den omreglerade marknaden gick det fem farmaceuter per apotek istället för sex, direktexpedieringen ökade dock med 1,6 procent mer. De totala kostnaderna ökade med 0,289 miljoner euro mindre och kostnaderna per person sjönk istället för att stiga, även priserna i detaljhandel föll mer med omregleringen än utan. Målet om ökad tillgänglighet och låga kostnader är således uppfyllt, målet om förbättrad service är uppfyllt till viss grad. Den totala bedömningen av omregleringen är att den varit lyckad. Sweden's pharmacy market underwent a reregulation year 2009 from a public monopoly to a market exposed to competition. The reason for the reform was liberalization influences in the economy during the nineties, in economic theory aswell as from becoming a member of the European Union. The reform was received with mixed feelings which was well reflected in the many contradictory assessment reports of the reregulation the following years. The lack of consensus about the goal fulfillment and the many impartial reviews leads to the purpose of this essay, to examine if the goals of the reform are fulfilled now nine years later or not. The goals of the reform are presented in proposition 2008/09:145 as following: increased accessibility, improved service and low costs for consumers and the government. The method is goal fulfillment with support in a counterfactual analysis, Sweden without reregulation, that is based upon Sweden before the reregulation with the application of Finland's development after 2009. The analyze examines the goal from nine aspects and lands in the fact that the market with reregulation shows a better result in eight out of nine of them compared with the result of the market without a reregulation. The reregulated market generated 434 more pharmacies and the number increased in nine out of ten areas with between 18,9 and 80,7 percent more than the non-reregulated market. The open hours were also 11,2 hours longer per week in the reregulated market. The total added number of pharmacist increased by 956 workers with the reregulation, however, the number of pharmacies increased at a greater rate and the relation between pharmacists and pharmacies worsened, more with the reregulation than without. On the reregulated market there were five pharmacists per pharmacy instead of six, however directly dispensed medicine increased with 1,6 percent more. Total governmental costs increased with 0,289 million euro less and the cost per person decreased instead of increased, also the prices in retail dropped more with the reregulation than without. The goal of increased accessibility and low costs are therefore fulfilled, the goal of improved service is fulfilled to a certain degree. The total assessment of the reregulation is that it has been successful.

Additional file 1 of Physicians’ challenges when working in the prehospital environment - a qualitative study using grounded theory

Supplementary Material

Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals

Background The benefits of helicopter emergency medical services (HEMS) transport of adults following major trauma have been examined with mixed results, with some studies reporting a survival benefit compared to regular emergency medical services (EMS). The benefit of HEMS in the context of the Swedish trauma system remains unclear.Aim To investigate differences in survival and prehospital time intervals for trauma patients in Sweden transported by HEMS compared to road ambulance EMS.Methods A total of 74,032 trauma patients treated during 2012-2022 were identified through the Swedish Trauma Registry (SweTrau). The primary outcome was 30-day mortality and Glasgow Outcome Score at discharge from hospital (to home or rehab); secondary outcomes were the proportion of severely injured patients who triggered a trauma team activation (TTA) on arrival to hospital and the proportion of severely injured patients with GCS &amp;lt;= 8 who were subject to prehospital endotracheal intubation.Results 4529 out of 74,032 patients were transported by HEMS during the study period. HEMS patients had significantly lower mortality compared to patients transported by EMS at 1.9% vs 4.3% (ISS 9-15), 5.4% vs 9.4% (ISS 16-24) and 31% vs 42% (ISS &amp;gt;= 25) (p &amp;lt; 0.001). Transport by HEMS was also associated with worse neurological outcome at discharge from hospital, as well as a higher rate of in-hospital TTA for severely injured patients and higher rate of prehospital intubation for severely injured patients with GCS &amp;lt;= 8. Prehospital time intervals were significantly longer for HEMS patients compared to EMS across all injury severity groups.Conclusion Trauma patients transported to hospital by HEMS had significantly lower mortality compared to those transported by EMS, despite longer prehospital time intervals and greater injury severity. However, this survival benefit may have been at the expense of a higher degree of adverse neurological outcome. Increasing the availability of HEMS to include all regions should be considered as it may be the preferrable option for transport of severely injured trauma patients in Sweden.Funding Agencies|Karolinska Institute</p

Trauma patient transport to hospital using helicopter emergency medical services or road ambulance in Sweden: a comparison of survival and prehospital time intervals

Abstract Background The benefits of helicopter emergency medical services (HEMS) transport of adults following major trauma have been examined with mixed results, with some studies reporting a survival benefit compared to regular emergency medical services (EMS). The benefit of HEMS in the context of the Swedish trauma system remains unclear. Aim To investigate differences in survival and prehospital time intervals for trauma patients in Sweden transported by HEMS compared to road ambulance EMS. Methods A total of 74,032 trauma patients treated during 2012–2022 were identified through the Swedish Trauma Registry (SweTrau). The primary outcome was 30-day mortality and Glasgow Outcome Score at discharge from hospital (to home or rehab); secondary outcomes were the proportion of severely injured patients who triggered a trauma team activation (TTA) on arrival to hospital and the proportion of severely injured patients with GCS ≤ 8 who were subject to prehospital endotracheal intubation. Results 4529 out of 74,032 patients were transported by HEMS during the study period. HEMS patients had significantly lower mortality compared to patients transported by EMS at 1.9% vs 4.3% (ISS 9–15), 5.4% vs 9.4% (ISS 16–24) and 31% vs 42% (ISS ≥ 25) (p < 0.001). Transport by HEMS was also associated with worse neurological outcome at discharge from hospital, as well as a higher rate of in-hospital TTA for severely injured patients and higher rate of prehospital intubation for severely injured patients with GCS ≤ 8. Prehospital time intervals were significantly longer for HEMS patients compared to EMS across all injury severity groups. Conclusion Trauma patients transported to hospital by HEMS had significantly lower mortality compared to those transported by EMS, despite longer prehospital time intervals and greater injury severity. However, this survival benefit may have been at the expense of a higher degree of adverse neurological outcome. Increasing the availability of HEMS to include all regions should be considered as it may be the preferrable option for transport of severely injured trauma patients in Sweden

Physician-staffed prehospital units: a retrospective follow-up from an urban area in Scandinavia

BackgroundThe aim of this study was to determine when and how rapid response vehicles (RRVs) make a difference in prehospital care by investigating the number and kinds of RRV assignment dispatches and the prehospital characteristics and interventions involved.MethodsThis retrospective cohort study was based on data from a quality assurance system where all assignments are registered. RRV staff register every assignment directly at the site, using a smartphone, tablet, or computer. There is no mandatory information requirement or time limit for registration. The study includes data for all RRVs operating in Region Stockholm, three during daytime hours and one at night - from January 1, 2021 to December 31, 2021.ResultsIn 2021, RRVs in Stockholm were dispatched on 11,283 occasions, of which 3,571 (31.6%) resulted in stand-downs. In general, stand-downs were less common for older patients. The most common dispatch category was blunt trauma (1,584 or 14.0%), which accounted for the highest frequency of stand-downs (676 or 6.0%). The second most common category was cardiac arrest (1,086 or 9.6%), followed by shortness of breath (691 or 6.1%), medical not specified (N/S) (596 or 5.3%), and seizures (572 or 5.1%).ConclusionThe study findings confirm that RRVs provide valuable assistance to the ambulance service in Stockholm, especially for cardiac arrest and trauma patients. In particular, RRV personnel have more advanced medical knowledge and can administer medications and perform interventions that the regular ambulance service cannot provide.Funding Agencies|Linkoping University.; Capio Laekarbilar AB; Dan Gryth Memorial Fund</p