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	<title>Sweden | American HealthScare</title>
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	<description>How the healthcare industry&#039;s scare tactics have screwed up our economy -- and our future</description>
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		<title>It’s Too Soon to Judge the Swedish Approach to COVID-19</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/its-too-soon-to-judge-the-swedish-approach-to-covid-19/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/its-too-soon-to-judge-the-swedish-approach-to-covid-19/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Wed, 22 Jul 2020 02:56:12 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[Covid-19]]></category>
		<category><![CDATA[deaths]]></category>
		<category><![CDATA[epidemiology]]></category>
		<category><![CDATA[Incidence]]></category>
		<category><![CDATA[mortality]]></category>
		<category><![CDATA[New Zealand]]></category>
		<category><![CDATA[SARS-Cov-2]]></category>
		<category><![CDATA[statistics]]></category>
		<category><![CDATA[Sweden]]></category>
		<category><![CDATA[United States]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1391</guid>

					<description><![CDATA[<p>I assume my readers have a good idea of how Sweden has handled the COVID crisis compared to the rest of Europe. Briefly, they kept their schools, restaurants, and bars open with voluntary precautions in place. Critics have concluded this was a mistake, because there have been a lot more deaths there than neighboring countries. As of July 20, 2020, this is a true statement, but it is way too early to conclude that the Swedish approach was a mistake. First, let’s review the facts up-to-date in total: Country&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Population&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; COVID cases&#160;&#160;&#160;&#160;&#160;&#160; COVID deaths Sweden&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 10.2 million&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 78,000&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 5,639 Denmark&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 5.2 million&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 13,466&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 611 Norway&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 5.4 million&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 9,000&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; 255 &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; I tried to look up hospitalizations, but many countries don’t report this. &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; These are the reported national statistics, but there are many gaps. In the early days of the infection and there weren’t enough test kits, many people around the world with mild to no symptoms were never tested. Plus, I think there is still uncertainty about the accuracy of all COVID tests. There are many anecdotes of people testing positive with one method and negative with another, not explained by recovery time. &#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160;&#160; Clearly, a lot more people [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/its-too-soon-to-judge-the-swedish-approach-to-covid-19/">It’s Too Soon to Judge the Swedish Approach to COVID-19</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>            I assume my readers have a good idea of how Sweden has handled the COVID crisis compared to the rest of Europe. Briefly, they kept their schools, restaurants, and bars open with voluntary precautions in place. Critics have concluded this was a mistake, because there have been a lot more deaths there than neighboring countries. As of July 20, 2020, this is a true statement, but it is way too early to conclude that the Swedish approach was a mistake.</p>



<p>             First, let’s review the facts up-to-date in total:</p>



<p>Country&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Population&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; COVID cases&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; COVID deaths</p>



<p>Sweden&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 10.2 million&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 78,000&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 5,639</p>



<p>Denmark&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 5.2 million&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 13,466&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 611</p>



<p>Norway&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 5.4 million&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 9,000&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 255</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; I tried to look up hospitalizations, but many countries don’t report this.</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; These are the reported national statistics, but there are many gaps. In the early days of the infection and there weren’t enough test kits, many people around the world with mild to no symptoms were never tested. Plus, I think there is still uncertainty about the accuracy of all COVID tests. There are many anecdotes of people testing positive with one method and negative with another, not explained by recovery time.</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Clearly, a lot more people have been infected than the national numbers suggest. Antibody testing (still likely imperfect) recently in New York City and Stockholm found that 17%-18% of their populations have antibodies to the virus. These numbers are based on random sampling, not the positive test rate of people with symptoms or known exposures. Similarly, 19% of the people on the Diamond Princess cruise ship had evidence they contracted the disease (712/3711) and 13 people died (0.4%, and if we can make some stereotypical assumptions about the average age of a cruise passenger, then the death rate in younger people must be substantially less). Just for Sweden, this means the ratio of actual cases to known cases is likely at least 25 times higher. The daily death rate in Sweden for the past week has been in the 0-3 range. COVID has nearly burned itself out there. If only 17-18% of the population is protected, but 60% or more of a population must be immune for herd immunity to exist, how can this be?</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The 2 explanations that make the most sense to me are 1) the tests still aren’t very accurate, and 2) lots of people have been infected by other corona viruses in the past that provide good cross-reactive protection. They don’t possess antibodies that are super specific to COVID-19, but they are still able to effectively bind to COVID-19 and call in the other immune system cells to destroy the virus. Corona viruses are not new. They are a common cause of common colds.</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Another criticism of the Swedish approach was that in spite of its efforts to keep its economy going throughout the pandemic, its economy will still contract similar to surrounding countries. The latest articles I can find predict that all of the 3 Scandinavian countries’ economies will contract about 4% this year. The final numbers probably won’t be tallied for a few years. Several commentators say that Sweden should have been expected to take a harder hit, because more of its economy is based on manufacturing (Volvo, IKEA, e.g.). The Norwegian estimates apparently don’t include its ailing oil and gas industry.</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; What does all of this mean for Denmark and Norway? It means that they have a long way to go. If the ratios are similar, it means that they are still a long way off from 18% having detectable COVID-19 antibodies. The latest number I could find was that as of 3 weeks ago, 1% of Norwegians are antibody positive and 1% of Danes about 2 months ago.</p>



<p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; What does this mean for the U.S.? It is clear that lots of people in the U.S. had mild to no cases of COVID infection already and were never tested, because the U.S. has had such a low supply of test kits. For the antibody prevalence approach, the CDC has launched a national study, but has released no results yet. An article from 3 weeks ago estimated that 5% of Connecticut and 7% of New York state had antibodies. As of today (July 20), 3.8 million Americans have been confirmed infected (1.2%) with 143,000 deaths.</p>



<p>             Death certificates also have limitations too, but they are probably the best source on which to estimate future cases. The total death rate in Sweden is .055%, 0.1% if we just look at the more crowded Stockholm County (4 times less than the Diamond Princess, which likely speaks to its skewed passenger demographic). The total death rate in New York state is 0.16%, or 3 times higher than Sweden, 0.27% if we just look at New York City. At least this puts us in an order-of-magnitude range.</p>



<p>              Let’s take a middle ground assumption of 0.1%. This means, without a vaccine, 328,000 Americans will die from COVID-19 before this is all over. At 143,000, we are almost halfway there. If we use the New York City death rate, then there will be about 894,000 deaths. There are still no effective treatments for COVID, other than supporting people who are so sick they are on a ventilator with some basic interventions such as steroids and maybe blood thinners.</p>



<p>                Now let’s talk about time frames. Sweden and New York ran through most of their deaths in about 3 ½ months, Sweden about 4 ½ months. Let’s compare with Denmark, which is destined to have 5,200 deaths, but has only had 611 so far. It’s been averaging about 24 deaths per day under a stricter lockdown policy. At this rate, Denmark will have finished out its COVID threat by about 6 months. And 6 months is the earliest a vaccine could reasonably be ready for widespread distribution. Just today, there was an announcement that the early phase research of one vaccine showed that it generated an immune response. Vaccine development history is littered with vaccines that generated immune responses, but didn’t protect people from the disease. We cannot assume that any of these COVID vaccines will work until there is proof that they work.</p>



<p>                 What about the U.S.? It’s been averaging about 750 deaths/day recently, which projects to our COVID pandemic mostly burning out in about 8 months. If we assume a higher death rate closer to New York state, then the number climbs to 17 months, 3 years if we assume the New York City death rate.</p>



<p>              Through the examples of Sweden and New York, we can draw conclusions on the natural history of the virus: Sweden through a conscious choice, New York through a lot of cases hitting it at once before it knew what was happening.</p>



<p>              The media has looked at countries such as New Zealand and South Korea as exemplars of how the U.S. should have reacted to the virus. New Zealand has had 0-3 deaths per day since May. Both countries are essentially islands that can, to some degree, block themselves from the rest of the world. But now what? Do they remain isolated from the rest of the world as long as COVID is lurking? If their gamble was that a vaccine will be developed by early 2021, then in terms of lives extended, if a successful vaccine is developed, it means they guessed right. If a vaccine is never successfully developed and New Zealand continues to have minimal exposure to the outside world, its COVID pandemic will burn out in about 13 years, 33 years at New York City death rates.</p>



<p>                The bummer for Sweden is that even if it is past the COVID crisis within its borders, the depressed worldwide economy will still affect the Swedish economy as companies like H&amp;M, IKEA, Volvo, and Electrolux will likely have decreased sales until the world economy rebounds. Maybe Spotify can prop up their economy in the meantime.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/its-too-soon-to-judge-the-swedish-approach-to-covid-19/">It’s Too Soon to Judge the Swedish Approach to COVID-19</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
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		<title>A Texas Longhorn in King Carl’s Clinic</title>
		<link>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/a-texas-longhorn-in-king-carls-clinic/</link>
					<comments>https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/a-texas-longhorn-in-king-carls-clinic/#comments</comments>
		
		<dc:creator><![CDATA[Richard Young MD]]></dc:creator>
		<pubDate>Mon, 20 May 2019 02:26:58 +0000</pubDate>
				<category><![CDATA[Blog]]></category>
		<category><![CDATA[Britain]]></category>
		<category><![CDATA[family physician]]></category>
		<category><![CDATA[healthcare systems]]></category>
		<category><![CDATA[NHS]]></category>
		<category><![CDATA[prevention]]></category>
		<category><![CDATA[Sweden]]></category>
		<category><![CDATA[UK]]></category>
		<guid isPermaLink="false">http://www.healthscareonline.com/?p=1352</guid>

					<description><![CDATA[<p>I had the distinct pleasure working with family physician colleagues in Sweden recently. It was a similar experience to a trip I made to Britain about 5 years ago that I also wrote about. I got to spend some time watching one of my colleagues care for her patients in her surgery (they use the same description of a clinic as the British). I got to spend some time watching one of my colleagues care for her patients in her surgery (they use the same description of a clinic as the British). The infrastructure was very similar to what I saw in Britain. It was a spacious office that included a physical therapist, a counselor, and at least one chronic disease nurse. They also had a fitness center at the end of the building. The waiting room is small, because patients don&#8217;t spend much time there. The family physicians’ offices large, much larger than the typical American office. It includes a desk and two chairs, and examination table, and other equipment such as a spirometer. The doctor stays in the same room all day and does not bounce from room to room. There were no in MAs, no screenings, no [&#8230;]</p>
The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/a-texas-longhorn-in-king-carls-clinic/">A Texas Longhorn in King Carl’s Clinic</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></description>
										<content:encoded><![CDATA[<p>I had the distinct pleasure working with family physician colleagues in Sweden recently. It was a similar experience to a trip I made to Britain about <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/a-visit-to-britains-national-health-service/">5 years ago that I also wrote about.</a> I got to spend some time watching one of my colleagues care for her patients in her surgery (they use the same description of a clinic as the British).</p>



<p> I got to spend some time watching one of my colleagues care for her patients in her surgery (they use the same description of a clinic as the British).</p>



<p>The
infrastructure was very similar to what I saw in Britain. It was a spacious
office that included a physical therapist, a counselor, and at least one chronic
disease nurse. They also had a fitness center at the end of the building.</p>



<p>The
waiting room is small, because patients don&#8217;t spend much time there. The family
physicians’ offices large, much larger than the typical American office. It
includes a desk and two chairs, and examination table, and other equipment such
as a spirometer. The doctor stays in the same room all day and does not bounce
from room to room.</p>



<p>There
were no in MAs, no screenings, no PHQ-9 questionnaires, and often no vital
signs were taken other than blood pressure in patients with pre-existing
hypertension. They need fewer employees per physician. All of the patients I saw
her care for were in their 80s who were there for their annual review. The
interviews were in Swedish, but another Swedish physician was with me and he
was able to type out what they were saying on an iPad.&nbsp;</p>



<p>Just
like in Britain, their EMR is so much easier to use than American EMRs, because
they are not loaded down with all the American baggage. There are almost no buttons
to click, no pop-ups, and no bill&#8217;s to fill out. After each visit, the family
physician spent 30 to 60 seconds dictating a note and that was it for her
documentation. A secretary in her office typed out the note that was much
shorter than an American Medicare-mandated bullet counting note bloat monstrosity.
The purpose of the note was to serve as a brief reminder to the physician of
what she did in the visit. That was it. The EMR included e-connections to the
pharmacy. To the degree the doctor looked at the computer instead of the
patient, it was almost entirely to click the prescription refill buttons after
the doctor and patient it talked about the related conditions.</p>



<p>For
further evidence that more prevention will not decrease healthcare costs, I
found that this physician was more comfortable with higher blood pressures in
her patients than American guidelines would tolerate. The other physician I was
with confirmed that this is common practice. They are worried that falls will increase
if the pressure gets too low. Also, there is essentially no primary prevention
of cholesterol disease with statins and Sweden. The doctors said that if a
patient had a really high family history of coronary disease or strokes and
asked to be on a statin they would probably prescribe it, but in general
statins are not prescribed until after someone has a heart attack, a coronary
artery procedure, or a stroke.</p>



<p>When I talked to Swedes who were not in the healthcare system,
they were generally very happy with their national system. There were some
complaints about long waiting times for elective surgeries and a national
shortage of nursing home beds. Others questioned if they were getting full
value for their investment in taxes. I met several people who had spent some
time in America, and they were the most vehement about how well the Swedish
system cares for his people, in contrast to some horror stories they told
about&nbsp;relatives back in the US.</p>



<p>There
are many similarities in how Sweden and Britain finance their healthcare
systems. One difference is that Sweden has a relatively small percentage of its
doctors who are family physicians, which they are trying to increase. Britain
has a looming shortage, but there are still many more there than in Sweden.</p>



<p>The
biggest difference for me between the systems is that in Britain the NHS is a
national religion. It&#8217;s always in the news and the general public thinks about
it a lot. In Sweden, as another example how prevention does not explain lower national
healthcare costs, they only provide colonoscopy for cancer screening in
Stockholm and Gothenburg. They want to expand the service to other regions, but
it won&#8217;t happen soon. I saw no angst or protests about this fact.</p>



<p>I
found the Swedish people to have a more passive acceptance than the British that
the national healthcare system will take care of them. Clearly someone in
Stockholm is making rationing decisions, but I saw no evidence that those
decisions are anywhere as public and transparent as they are in Britain. Both
countries make difficult decisions to live within their means, but the Swedes
just choose not to worry about it. That&#8217;s not a criticism by any means, just an
observation of how they choose to spend their emotional energies. Instead of
worrying about national or regional healthcare policy decisions, they prefer to
spend their energy planning their next Fika (coffee break).</p>



<p>If only I liked coffee.</p>The post <a href="https://www.healthscareonline.com/http:/www.healthscareonline.com/blog/a-texas-longhorn-in-king-carls-clinic/">A Texas Longhorn in King Carl’s Clinic</a> first appeared on <a href="https://www.healthscareonline.com">American HealthScare</a>.]]></content:encoded>
					
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