Sweden has a total population of just >10 million, mostly (85%) in urban areas, and almost one-third with at least one parent born abroad. A mainly publicly financed healthcare system is in place, with low out-of-pocket costs for hospitalizations, procedures, and prescription drugs, also covering treatment that cannot be deferred for asylum seekers and migrants without papers. Medical education in Sweden is free, there are no tuition fees, with student grant and loan systems in place for subsistence. Residency in cardiology generally takes at least 5 years, with parts tailored to the resident’s specific interests.

Age-standardized death rates from ischemic heart disease, the largest contributor to cardiovascular mortality, declined markedly in Sweden, from 750 to 174 per 100 000 between 1980 and 2014 in men and from 404 to 94 in women.¹ This is still higher than in some Mediterranean countries, and, in men <65 years of age, the last recorded estimates show that 1 in 8 deaths (12.4%) was caused by ischemic heart disease.

What sets out Sweden, in comparison with other countries, is the Swedish preoccupation with measurement of routine statistics not only in health care and mortality, but also in performance. Sweden has a long history of national administrative registries, which are not only a gold mine for research, but also increasingly an instrument for improving the quality of care. The National Patient Register contains all inpatient (1987–2013) and nonprimary outpatient care (2001–2013) visits, but not primary care visits, and there is a lack of detail with respect to clinical and laboratory data and to management.

In the past 3 decades, therefore, an increasing number of nationwide healthcare quality registries focusing on specific disorders have been initiated, mostly by members of the medical profession, and supported by public means. Recorded data are used for quality improvement, monitoring of adherence to guidelines, and research. Patients must be informed that their data will be recorded and have the opportunity to opt out, a right that, in practice, is seldom exercised. Through linkage to other registries, using the personal identity number unique to all citizens, it is possible to estimate the proportion of potential patients included and to obtain mortality data.

Quality registries include data on clinical history, laboratory investigations, pharmaceutical and interventional treatments in-hospital, and at discharge. Some registries have initiated blood and tissue samples for biobanking. The registry data are merged on a regular basis with the public registries on vital status, deaths, new hospital admissions, new interventional procedures, and medications.

There are several quality registries relevant to cardiovascular diseases. SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies https://www.ucr.uu.se/swedeheart/) is the largest, documenting patients hospitalized with ischemic heart disease, coronary angiographies and percutaneous coronary interventions, all heart surgery, secondary prevention, and, since 2010, all percutaneous valve procedures.^2,3 Currently, all 69 hospitals with acute coronary care in Sweden participate in SWEDEHEART with ≈34 000 cases annually, of which 18 000 are myocardial infarctions, or >90% of all episodes reported to the National Patient Register. Through regular cross-linkages, SWEDEHEART data now cover essentially every patient admitted to any hospital for cardiac care from the first presentation until death.

The main purpose of SWEDEHEART and of other quality registries is to support improvement in the quality of care and adherence to Swedish and international treatment guidelines, accomplished by

bottom-up organization of the registries that are developed and run by user groups consisting of physicians and nurses from all participating hospitals

information technology systems that record and automatically check correctness of data

continuous on-line feedback to hospitals on patient mix, management, and outcomes with predesigned text and graphical reports on changes of care over time in relation to quality scores

annual reports and biannual applications whereby the registries obtain continued economic support.

The carefully documented changes and differences in patient care for acute coronary syndromes are monitored by the local healthcare providers and are, as required, leading to local quality development programs. The yearly public presentation of the detailed results receives attention from local and national media and is discussed by opinion leaders and politicians at different levels. These open and transparent processes have led to substantially improved compliance with national guidelines. Thereby, both the morbidity and mortality have decreased markedly during the past decades (Figure).³

Figure. Implementation of treatments and 1-year outcome in non–ST-segment–elevation myocardial infarction (NSTEMI) in SWEDEHEART 1995–2014. A, Implementation of in-hospital interventions and discharge medications. B, Frequency of events in the first year after admission for NSTEMI. ACE indicates angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; CABG, coronary artery bypass grafting; and PCI, percutaneous coronary intervention. Adapted from Szummer et al³ with permission. Copyright © 2018, Oxford University Press.

During the past years, the SWEDEHEART information technology infrastructure has been developed to facilitate and support the performance of registry-based prospective randomized trials⁴ within the registries and also to support continuous safety surveillance of implanted devices.⁵ Thereby, the registry information technology system will support enrollment, randomization, and collection of baseline data, whereas follow-up mainly will be performed by merging with other registries. This approach has led to international attention, eg, based on the presentation of the TASTE trial (Thrombus Aspiration in Myocardial Infarction)⁴ on thrombectomy, and others. Several registry-based prospective randomized trials are currently ongoing and are listed on the homepage of SWEDEHEART.

Other than the SWEDEHEART registry, there are several other cardiovascular quality registries with high coverage (≥80%), such as the Cardiac Arrest Registry, the SWEDVASC (National Quality Registry for Vascular Surgery) for noncardiac vascular procedures, the SWEDCON (National Quality Registry for Congenital Heart Disease) for children and adults with congenital heart disease, and the Catheter Ablation Registry. The Heart Failure Registry and the AuriculA Registry (atrial fibrillation), in part, driven in the outpatient setting, have lower coverage.

Challenges for the future include the increasing costs to provide equal and high-quality health care to everybody in an ageing population, potential disrupting effects on the public healthcare system of the widening social differences, and the increasing issue of individuals with overweight, obesity, and sedentary lifestyle putting an additional strain on healthcare resources. Even so, unique Swedish registries will at least help in keeping tabs on ongoing developments, to optimize health system performance, to provide high-quality and equitable care to all citizens, and to allocate resources and interventions where they are most needed.

None.

https://www.ahajournals.org/journal/circ

瑞典的总人口只有1000万，其中大部分（85％）位于城市地区，近三分之一的人口中至少有一位父母是在国外出生的。目前已经建立了一个主要由公共财政资助的医疗系统，住院，治疗和处方药的自付费用较低，还涵盖了没有证件的寻求庇护者和移民无法享受的治疗。瑞典的医学教育是免费的，没有学费，并且设有助学金和贷款制度以维持生计。心脏病住院时间通常至少需要5年，而部分时间则根据居民的特定兴趣量身定制。

缺血性心脏病的年龄标准化死亡率是造成心血管疾病死亡的最大原因，在瑞典显着下降，男性从1980年至2014年从每10万的750降至174，男性从404降至94。¹这仍然高于某些地中海国家/地区，并且在＜65岁的男性中，最新记录显示，八分之一的死亡（12.4％）是由缺血性心脏病引起的。

与其他国家相比，瑞典的重点是瑞典人不仅关注医疗保健和死亡率方面的常规统计数据，而且还关注绩效方面的常规统计数据。瑞典的国家行政机关历史悠久，不仅是研究的金矿，而且日益成为改善护理质量的工具。国家病人登记簿包含所有住院（1987-2013年）和非基层门诊（2001-2013年）就诊，但不包括基层就诊，并且在临床和实验室数据以及管理方面缺乏详细信息。

因此，在过去的30年中，已经启动了针对特定疾病的全国范围的医疗保健质量注册中心，越来越多的注册机构，主要是由医学专业人士提供，并得到了公众的支持。记录的数据可用于质量改进，监视对准则的遵守情况以及进行研究。必须告知患者其数据将被记录并有机会选择退出，而这项权利在实践中很少行使。通过与其他注册表的链接，使用所有公民独有的个人身份号码，可以估算出所包括的潜在患者的比例并获得死亡率数据。

质量注册表包括有关临床病史，实验室检查，医院内和出院时的药物和介入治疗的数据。一些登记处已启动血液和组织样本以进行生物存储。注册表数据会定期与公共注册表合并，其中包括生命状况，死亡，新住院，新的介入程序和药物。

有几个与心血管疾病相关的质量注册表。SWEDEHEART（瑞典网络系统，用于根据建议的治疗方法评估心脏病的循证护理的增强和发展，https：//www.ucr.uu.se/swedeheart/）是最大的，记录了住院缺血性心脏病的患者，冠状动脉造影和经皮冠状动脉介入治疗，所有心脏手术，二级预防以及自2010年以来的所有经皮瓣膜手术。^2,3目前，瑞典的全部69家接受急性冠状动脉护理的医院每年参加SWEDEHEART的病例约为3.4万例，其中有18000例是心肌梗塞，占国家病人登记簿报告的全部发作的90％以上。通过定期的交叉链接，SWEDEHEART数据现在基本上涵盖了从首次出现到死亡的每家入院接受心脏护理的患者。

SWEDEHEART和其他质量注册机构的主要目的是支持改善护理质量以及遵守瑞典和国际治疗指南，

由所有参与医院的医师和护士组成的用户组开发和管理的注册管理机构的自下而上组织

记录并自动检查数据正确性的信息技术系统

通过预先设计的文本和图形报告，就医疗服务随时间的变化与质量得分相关的信息，连续不断地向医院反馈有关患者的组成，管理和结果的信息

年度报告和半年申请，从而使注册管理机构获得持续的经济支持。

由当地医疗保健提供者监视并详细记录了急性冠脉综合征患者护理的变化和差异，并根据需要制定了本地质量开发计划。详细结果的年度公开展示受到本地和国家媒体的关注，并由不同级别的舆论领袖和政治家进行讨论。这些开放和透明的过程大大提高了对国家准则的遵守程度。因此，在过去的几十年中，发病率和死亡率均显着下降（图）。³

数字。 在1995–2014年的SWEDEHEART中，非ST段抬高型心肌梗死（NSTEMI）的治疗实施和1年结局。A，医院内干预措施和出院药物的实施。B，NSTEMI入院后第一年的事件发生频率。ACE表示血管紧张素转化酶；ARB，血管紧张素II受体阻滞剂；CABG，冠状动脉搭桥术；和PCI，经皮冠状动脉介入治疗。改编自Szummer等人³。版权所有©2018，牛津大学出版社。

在过去的几年中，已经开发了SWEDEHEART信息技术基础架构，以促进和支持注册表中基于注册表的前瞻性随机试验⁴的性能，并支持对植入设备的连续安全监视。⁵因此，注册管理机构信息技术系统将支持注册，随机化和收集基准数据，而后续活动将主要通过与其他注册管理机构合并来进行。这种方法已经引起了国际关注，例如，以TASTE试验（心肌梗死中的血栓抽吸术）的介绍为基础⁴进行血栓切除术等。目前正在进行多项基于注册表的前瞻性随机试验，并在SWEDEHEART的主页上列出。

除了SWEDEHEART注册中心外，还有其他覆盖率较高（≥80％）的心血管质量注册中心，例如，心脏骤停注册中心，用于非心脏血管手术的SWEDVASC（国家血管外科质量注册中心），SWEDCON（国家质量注册中心）先天性心脏病患者）和导管消融注册中心。心衰注册和AuriculA注册（心房颤动）部分是由门诊患者驱动的，覆盖率较低。

未来的挑战包括：为人口老龄化中的每个人提供平等和高质量的医疗服务的成本不断增加；不断扩大的社会差异对公共医疗体系的潜在破坏作用；以及超重，肥胖和久坐的生活方式给医疗资源增加了压力。即便如此，独特的瑞典注册管理机构至少将有助于保持与时俱进的发展，优化卫生系统的绩效，为所有公民提供高质量和公平的护理以及在最需要的地方分配资源和干预措施。

没有。

https://www.ahajournals.org/journal/circ