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This article gives an overview of the current use of the main clinical classifications in the Nordic countries. A brief introduction describes the background and content of Nordic co-operation in the areas of health statistics and health-related classifications. The use of the current international classifications is well established in the Nordic countries. Some Nordic classifications have been developed in co-operation with maintenance and updating performed as a joint Nordic responsibility.

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.

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.

Patient questionnaires are commonly used to assess patient satisfaction. This study reports on methodological experiences based on practical use of a Swedish questionnaire. The material consists of questionnaires from five different studies at some 60 wards in three hospitals. Four of the studies were performed by "routine procedure", while one was performed specially to study sampling, non-response and other losses. The results showed that a large number of patients were not given a questionnaire despite the fact that they should have been included according to the sampling criteria. In the special study barely half of those discharged answered a questionnaire corresponding to only about one in four in some studies performed routinely. Many of the patients excluded were probably in a difficult situation and their needs ought to be particularly noticed. This was true of patients who were old or confused, had language difficulties, were seriously ill, or who died during the care episode.

A review of 106 nursing records from 12 wards was conducted to categorize and quantify the content of the documentation and to consider the comprehensiveness of the recording for individual nursing problems. Audit instruments, based on a model for nursing documentation were developed and applied. The results show that admission assessment was missing in slightly less than half of all records, two-thirds had no nursing care plan and about one-third had no documentation on nursing outcome. About 90% of the records had no nursing diagnosis, no objective or no nursing discharge note. Notes on nursing status and nursing interventions were most common. Only one-third of the nursing problems identified had recording that gave information about the progress of the patient's problem. The analyses performed give information on the quality of nursing records which may be used to evaluate the quality of nursing care.

Avoidable mortality in Sweden 1974-1985 was analysed using a European Community (EC) Working Group list of 'avoidable death indicators." The list includes causes of death that in certain age groups were defined as indicators of the outcome of medical care intervention or for some conditions, indicators of the national health policies. About 10 out of 14 medical health care indicators occurred in less than 50 cases per year. Death rates decreased over the 12-year period studied for most avoidable death indicators. For women, however, the death rate for malignant neoplasms of the trachea, bronchus and lung increased significantly. Swedish total mortality for ages 5-64 years was lower than the EC standards 1974-1978 and 1980-1984. Most of the avoidable causes of death had a relatively low standard mortality rate (SMR) when compared to both the EC standard and to the Swedish SMR for total mortality. For asthma, however, the Swedish SMR was higher. The development and implementation of the avoidable death concept and methodology is discussed.

The use of individual-based data in research has recently come in for much discussion. The basic issue of the discussion is how to balance between different legitimate interests: the interest in improving knowledge on matters important to human health and the interest in respecting individual autonomy. In this paper we will use a model for description and analysis of ethical conflicts in individual-based research. The model consists of two dimensions: the first specifies the persons involved in the conflict, the second specifies the relevant ethical principles. We have chosen the case of the Rönnskär study as an example. For illustration we distinguish between: no study, a study without informed consent and a study with informed consent. In the Rönnskär study the decision between the three situations rests upon an assessment of the conflict between two obligations: to improve the working environment and to respect autonomy.