Abstract

The aim of this study was to identify trends in hospitalization for diabetes mellitus and their correlation with the Family Health Strategy (FHS) coverage in the state of Paraná, by Health District (HD), between 2000 and 2012. It is an ecological study based on secondary data from the Hospital Information System of the Brazilian Unified Health System and the Primary Care Department. There was downward trend for general admission rates (from 10.2 to 9.0/10,000 inhabitants), but upward trend for some HDs. No correlation was observed between admission rates and the FHS coverage for the state. However, there was strong inverse correlation for Paranaguá, Metropolitan, Foz do Iguaçu and Umuarama HDs, and strong and direct correlation for Pato Branco, Campo Mourão, Cianorte, Telêmaco Borba and Ivaiporã HDs. Overall, hospitalizations for diabetes mellitus proved to be decreasing and without correlation with FHS coverage; however, there were differences according to HDs.

Key words
Diabetes Mellitus; Hospitalization; Family Health Strategy; Public health care services coverage; Primary Health Care

Introduction

The prevalence of Diabetes Mellitus is estimated to increase considerably by 2030 among the elderly in European countries and in the United States, and among people of all ages in developing countries, with a twice as higher rate for those aged between 20 and 44 years old¹1. International Diabetes Federation. Diabetes atlas update 2012: Regional & Country Facctsheets. [acessado 2013 Dez 3]. Disponível em: http://www.idf.org/diabetes-atlas-update-2012-regional-country-factsheets
http://www.idf.org/diabetes-atlas-update... . In Brazilian capitals, the prevalence of self-reported diabetes among people older than 18 years old has risen from 5.3% to 5.6% between 2006 and 2011, but with differences as to age groups and regions²2. Brasil. Ministério da Saúde (MS). Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico: Vigitel 2011. Brasília: MS; 2011..

Between 1990 and 2000, diabetes stood out among chronic conditions that have determined an increase in the number of lost years of life adjusted by incapacity, accounting for 5% of the latter; in addition, it causes early deaths, compromises people's ability to work and the maintenance of family savings for future years, possibly due to acute and chronic complications of the disease, which results in high morbimortality rates and costs for health systems³3. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961..

Diabetes adverse trends require relevant political interventions that offer the sufficient and cost-effective attention³3. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 377(9781):1949-1961.. In this sense, it is worth highlighting that diabetes constitutes an Ambulatory Care-Sensitive Condition (ACSC), as there is evidence that the adequate performance of healthcare professionals and managers at the level of Primary Healthcare (PHC) can help reduce the number of hospitalizations and deaths, especially through the prevention of micro and macro-vascular complications in the care provided by Family Health Strategy (FHS) teams⁴4. Alfradique ME, Bonolo PF, Dourado I, Lima-Costa MF, Macinko J, Mendonça CS, et al. Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP – Brasil). Cad Saude Publica 2009; 25(6):1337-1349..

In this way, hospitalizations for ACSC (HACSC) serve as an indicator of hospital activity and, at the same time, as an indirect measurement of effectiveness, access and quality of PHC⁵5. Brasil. Ministério da Saúde (MS). Portaria 221, de 17 de abril de 2008. Diário Oficial da União 2008; 18 abr.. The ACSC Brazilian List (Decree 221-SAS/MS-2008) is a reference for the assessment of the FHS operation⁶6. Moura BLA, Cunha, RC, Aquino R, Medina MG, Mota ELA, Macinko J, Dourado I. Principais causas de internação por condições sensíveis à atenção primária no Brasil: uma análise por faixa etária e região. Rev. Bras. Saude Mater. Infant. 2010; 10(Supl. 1):583-591.. It is worth highlighting that, besides the list, there are also specific lists of the states of Minas Gerais and Ceará, and the municipality of Curitiba, in Paraná⁴4. Alfradique ME, Bonolo PF, Dourado I, Lima-Costa MF, Macinko J, Mendonça CS, et al. Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP – Brasil). Cad Saude Publica 2009; 25(6):1337-1349., and all of them contain the diabetes diagnosis, followed or not by coma or ketoacidosis⁴4. Alfradique ME, Bonolo PF, Dourado I, Lima-Costa MF, Macinko J, Mendonça CS, et al. Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP – Brasil). Cad Saude Publica 2009; 25(6):1337-1349..

Considering that PHC is implemented in Brazil through the FHS, the increase in the FHS population coverage should lead to a decrease in morbimortality from ACSC, such as diabetes⁶6. Moura BLA, Cunha, RC, Aquino R, Medina MG, Mota ELA, Macinko J, Dourado I. Principais causas de internação por condições sensíveis à atenção primária no Brasil: uma análise por faixa etária e região. Rev. Bras. Saude Mater. Infant. 2010; 10(Supl. 1):583-591.. Studies of HACSC in Brazil have focused on identifying what evitable causes most cause hospitalizations in the Brazilian population⁵5. Brasil. Ministério da Saúde (MS). Portaria 221, de 17 de abril de 2008. Diário Oficial da União 2008; 18 abr.^,77. Rehem TCMSB, Oliveira MRF, Amaral TCL. Internações por condições Sensíveis à Atenção Primária em uma metrópole brasileira. Revista da Escola de Enfermagem da USP 2013; 47(4):884-890.. Concerning diabetes, more specifically, three international studies have been found, which addressed this disease and its relationship with the care provided in PHC, conducted in Philadelphia⁸8. Robbins JM, Valdmanis VG, Webb DA. Do public health clinics reduce rehospitalizations?: the urban diabetes study. J Health Care Poor Underserved 2008; 19(2):562-573., United States in general⁹9. Niefeld MR, Braunstein JB, Wu AW, Saudek CD, Weller WE, Anderson GF. Preventable hospitalization among elderly Medicare beneficiaries with type 2 diabetes. Diabetes Care 2003; 26(5):1344-1349., and Ontario, Canada¹⁰10. Booth GL, Hux JE. Relationship between avoidable hospitalizations for diabetes mellitus and income level. Archiv Intern Med 2003; 163(1):101-106.. A study conducted with data on hospitalizations for diabetes in Ceará is an advancement, as it points the trends of hospitalization rates by sex and age group, but does not establish a correlation with the FHS coverage¹¹11. Santos FAL, Lima WP, Santos AL, Teston EF, Marcon SS. Hospitalizações por diabetes em adultos e idosos no Ceará, 2001-2012. Epidemiol. Serv Saúde 2014; 23(4):655-663..

In addition, the FHS coverage is a vital component in the operationalization of PHC and should be considered in the assessment of universal health systems, because it indicates the set of actions and services to which the population has acess¹²12. Lobato LVC, Giovanella L. Sistemas de saúde: origens, componentes e dinâmica. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2008. p. 89-119..

Thus, the question is: what is the trend of hospitalization for diabetes rates in the state of Paraná? Is there any correlation between rates of hospitalization for diabetes and the FHS coverage? In this way, the present study aimed to identify rate trends of hospitalization for diabetes mellitus and their correlation with the FHS coverage in the state of Paraná, according to Health Districts, from 2000 and 2012.

Methods

This is a time-series study about rates of hospitalization for diabetes among residents of the state of Paraná, and about the time evolution of the FHS population coverage in the same state, according to 22 HDs, from 2000 to 2012. Population information about Paraná and its HDs were obtained from results of the 2000 and 2010 Demographic Census, and also from inter-census estimates provided by the Brazilian Institute of Geography and Statistics. Data on hospitalization for diabetes were collected from the Hospital Information System (Sistema de Informações Hospitalares) of the Brazilian Unified Health System (Sistema Único de Saúde) SUS, available at the website of SUS's IT Department, between February and March 2014.

Hospitalization rates were calculated for each HD through the ratio between the absolute frequency of hospitalizations for diabetes and the residing population, using the interval from E-10 to E-14 of Chapter IV of the International Classification of Diseases, version 10 (ICD-10). Subsequently, hospitalization rates, calculated on a base of 10,000 inhabitants, were standardized by means of direct method, having as standard the population of each region and the state of Paraná in 2010.

Data on the population covered by the FHS were collected from the website of the Primary Healthcare Department (Departamento da Atenção Básica) of the Brazilian Ministry of Health. The next step was the calculation of estimated population coverages of the FHS for the state of Paraná and for each HD, adopting as base the population covered in December of each year of the historical series. Afterwards, this study used the ratio between the population covered by the FHS and the population residing in the region, the series year, and then multiplied it by 100 for the calculation of the estimated population coverage, represented by percentage values.

The Shapiro-Wilk test for normality was carried out, which is recommended for samples with size smaller than 30, in order to verify the distribution of data collected, for both hospitalization rates and population coverage. Later, for data with normal distribution, the Pearson Correlation test was applied, and for non-normal data, the Spearman Correlation test; from the correlation matrix it was possible to analyze the relationship between the behavior of hospitalizations for diabetes and the evolution in FHS coverage; the hospitalization rates met the normality supposition. In order to classify the intensity of correlation coefficients, this study adopted the following categorization: correlation coefficients < 0.4 (weak correlation), ≥ 0.4 to < 0.5 (moderate correlation) and ≥ 0.5 (strong correlation)¹³13. Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Delineando a pesquisa clínica: uma abordagem epidemiológica. 3a ed. Porto Alegre: Artmed; 2008.. Cases in which no significance was found in the correlation test (p > 0.05) were regarded as “without correlation”. The coefficients also indicated direct or inverse correlation, according to the coefficient sign (positive or negative).

In the trend analysis, data corresponding to the 2000-2012 historical series were adjusted by polynomial regression models, which allow for the estimation of a statistical model for historical series, from which it is possible to verify the series behavior and indicate factors that are supposedly associated with this behavior. This type of analysis was chosen due to easy elaboration and interpretation of models and great statistical power¹⁴14. Latorre MRDO, Cardoso MRA. Time series analysis in epidemiology: an introduction to methodological aspects. Rev Bras Epidemiol 2001; 4(3):145-152..

Hospitalization rates composed the dependent variable (Y), and the calendar years of the study the independent variable (X), based on the assumption that the hospitalization rates varied over time, under the influence, in the case of the present study, of the FHS coverage. In order to prevent self-correlation between equation terms of the regression, the “year” variable was turned into “centralized year” variable, which is obtained by “year” minus the medium point of the historical series (year – 2003). The first model to be tested was simple linear regression (Y = β₀ + β₁Χ) and, then, models of higher degree were tested: second order (Y = β₀ + β₁Χ + β₂X₂) and third order (Y = β₀ + β₁Χ + β₂ X₂ + β₃Χ₃).

For the choice of the model, there was analysis of the dispersion diagram, the determination coefficient value (r² closer to 1 corresponds to a better adjustment of the model) and the residue distribution, which, in turn, allowed verifying the data homoscedasticity supposition. In cases of statistical equality between models, the model of lower order was chosen (first order or linear model). The series were smoothened through the 3-point moving average. All data were stored in tables on Tabwin 2.7 (Datasus app for data tabulation and treatment) and then shifted to Microsoft Excel 2010, where they were organized into databases. Polynomial regression models were generated from SPSS, version 20. The level of significance adopted was p < 0.05 (5%) for all tests performed.

The research project that resulted in the present study was approved by the Ethics Committee on Research Involving Humans of the State University of Maringá (COPEP/UEM), under legal opinion.

Results

Between 2000 and 2012, 111,402 hospitalizations for diabetes were recorded in the state of Paraná. The highest number of hospitalizations (21,436/19, 2%) was recorded in the Metropolitan HD, followed by Maringá, with 9,487 (8.5%), Londrina, with 7,445 (6.7%), and Ponta Grossa, with 6,986 hospitalizations for diabetes (6.3%). The FHS coverage in Paraná rose from 27.0% to 56.2% in the period studied, representing an increase of approximately 108% (percentage variation = 29.2%). Among the HDs, Apucarana showed the highest percentage of FHS coverage, both in the beginning (76.8%) and in the end of the period (96.1%). (Table 1).

Concerning hospitalization rates, the state of Paraná showed reduction from 10.4 to 9.3 hospitalizations/10,000 inhabitants. In the beginning of the period, Umuarama health district showed the highest hospitalization rate (26.9 hospitalizations/10,000 inhab.), and Foz do Iguaçu presented the lowest (5.4 hospitalizations/10,000 inhabitants). In the end of the period, Cornélio Procópio showed the highest rate (21.9 hospitalizations/10,000 inhab.), and Irati the lowest (1.5 hospitalizations/10,000). Cornélio Procópio showed high rates permanently, always around or higher than 20 hospitalizations/10,000 inhab. The highest rate found was 37.2 hospitalizations/10,000, in Umuarama health district, from 2004 to 2005 (Table 1).

Regarding hospitalization trends, it was found that in nearly 2/3 of the HDs (14 HDs), hospitalizations for diabetes increased, seven HDs showed downward trend, and only one showed stability. Ivaiporã, Telêmaco Borba and Jacarezinho health districts were those with the highest yearly medium increments, representing an increase of almost 1 hospitalization/10,000 inhabitants/year. Umuarama HD showed the highest historical average (29.9), but has been showing downward trend in hospitalization rates, having the greatest yearly average reduction observed, which was 2.4 hospitalizations/10,000 inhabitants. Londrina and the Metropolitan HDs were also among those which showed the greatest average reduction. Though stable, hospitalization rates in Cornélio Procópio HD presented a historical average of about 22 hospitalizations/10,000 inhabitants (Table 2).

There was no correlation between hospitalization rates and the FHS population coverage. However, strong and inverse correlation was found for Paranaguá, Metropolitan, Foz do Iguaçu and Umuarama health districts. Pato Branco, Campo Mourão, Cianorte Telêmaco Borba and Ivaiporã districts, in turn, showed strong and direct correlations. There was no correlation for the remaining districts (Table 3).

Figure 1 shows that Cornélio Procópio HD (18^th HD), lighter in the map, was the only presenting stability. There is some proximity between the HDs that presented linear upward and upward trend most of the time – the darker ones in the map.

Figure 2 shows some proximity between the HDs that presented strong positive or negative correlation.

Discussion

The greater proportion of hospitalizations in the Metropolitan HD can be explained by the larger population residing in that region, especially because it is where the most populous city in Paraná is located, Curitiba. The present study found reduction in hospitalization rates and strong correlation with the expansion in the number of FHS teams in the Metropolitan HD.

The 108% rise in the FHS population coverage was higher than that observed in Brazil between 1998 and 2006, which stood at 86.5%¹⁵15. Ceccon RF, Borges DO, Paes LG, Klafke JZ, Viecili PRN. Mortalidade por doenças circulatórias e evolução da estratégia da saúde da família no Brasil: um estudo ecológico. Cien Saude Colet 2013; 18(5):1411-1416., and in Minas Gerais, between 2000 and 2010, where the relative difference between coverages in the beginning and end of the period oscillated between 26.5% and 74.8%, according to HDs¹⁶16. Rodrigues-Bastos RM, Campos EMS, Ribeiro LC, Bastos-Filho MG, Bustamante-Teixeira MT. Internações por condições sensíveis à atenção primária, Minas Gerais, 2000 e 2010. Rev Saude Publica 2014; 48(6):958-967.. Considering Paraná’s territorial dimensions and administrative divisions, this increase in coverage represents the progress of the process to reorient PHC and the gradual overcoming of barriers in the access to services and socioeconomic differences between the HDs¹⁵15. Ceccon RF, Borges DO, Paes LG, Klafke JZ, Viecili PRN. Mortalidade por doenças circulatórias e evolução da estratégia da saúde da família no Brasil: um estudo ecológico. Cien Saude Colet 2013; 18(5):1411-1416.. About said differences, the division of the state into HDs represents the decentralization of healthcare proposed by the Ministry of Health in Brazil, as it is believed that this model of organization, based on regionalization, favors the access to and efficiency of healthcare networks¹⁵15. Ceccon RF, Borges DO, Paes LG, Klafke JZ, Viecili PRN. Mortalidade por doenças circulatórias e evolução da estratégia da saúde da família no Brasil: um estudo ecológico. Cien Saude Colet 2013; 18(5):1411-1416..

The drop in rates of hospitalization for diabetes in Paraná, in general, was also observed in the state of Minas Gerais, 0.85 to 0.80 hospitalizations/1,000 inhabitants, between 2000 and 2010¹⁶16. Rodrigues-Bastos RM, Campos EMS, Ribeiro LC, Bastos-Filho MG, Bustamante-Teixeira MT. Internações por condições sensíveis à atenção primária, Minas Gerais, 2000 e 2010. Rev Saude Publica 2014; 48(6):958-967.; in the capital city Campo Grande, 5.9 to 3.1 hospitalizations/10,000 inhabitants, between 2000 and 2009¹⁷17. Campos AZ, Theme-filha MM. Internações por condições sensíveis à atenção primária em Campo Grande, Mato Grosso do Sul, Brasil, 2000 a 2009. Cad Saude Publica 2012; 28(5):845-855.; and in the capital city Rio de Janeiro, among the elderly, 3.8 to 2.6 hospitalizations/1,000 inhabitants, from 2000 to 2010¹⁸18. Marques AP, Montilla DER, Almeida WS, Andrade CLT. Internação de idosos por condições sensíveis à atenção primária à saúde. Rev Saude Publica 2014; 48(5):817-826.. On the other hand, just as evidenced in the present study for HDs, for instance, Ivaiporã, there was an increase in the overall rate of hospitalization for diabetes in Juiz de Fora, between 2002 and 2009¹⁹19. Rodrigues-Bastos RM, Campos SEM, Ribeiro LC, Firmino RUR, Bustamante-Teixeira MT. Internações por condições sensíveis à atenção primária em município do sudeste do Brasil. Rev Assoc Bras 2013; 59(2):120-127.; in Guarulhos, with increase of 10% in hospitalizations, between 2008 and 2012²⁰20. Melo MD, Egry EY. Determinantes sociais das internações por condições sensíveis à atenção primária em Guarulhos, São Paulo. Rev Esc Enferm USP 2014; 48(Esp):133-140.; and even in Poland, between 2005 and 2009²¹21. Gajewska M, Gebska-Kuczerowska A, Gorynski P, Wysocki MJ. Analyses of hospitalization of diabetes mellitus patients in Poland by gender, age and place of residence. Annals Agric Environm Med 2013; 20(1):61-67..

Although downward trend has been found for the state of Paraná, in most part of the period, most of the HDs studied presented upward trend. In the state of Ceará, the overall trend of hospitalizations for diabetes was upward; however, the analysis stratified by sex performed found downward trend among women¹¹11. Santos FAL, Lima WP, Santos AL, Teston EF, Marcon SS. Hospitalizações por diabetes em adultos e idosos no Ceará, 2001-2012. Epidemiol. Serv Saúde 2014; 23(4):655-663.. As for Minas Gerais, the difference between 2000 and 2010 rates pointed significant overall reduction in rates; however, the regionalized analysis identified increase in two HDs¹⁶16. Rodrigues-Bastos RM, Campos EMS, Ribeiro LC, Bastos-Filho MG, Bustamante-Teixeira MT. Internações por condições sensíveis à atenção primária, Minas Gerais, 2000 e 2010. Rev Saude Publica 2014; 48(6):958-967..

Such results may vary largely according to economic, political and environmental determinants. A study conducted in Victoria, Australia, points that, in addition to diabetes and its complications being the main ACSC among hospitalizations of people older than 28 years old, variables such as sex, age, rurality, socioeconomic disadvantages and access difficulties are important predictors for increased hospitalizations²²22. Ansari Z, Haider SI, Ansari H, Gooyer T, Sindall C. Patient characteristics associated with hospitalisations for ambulatory care sensitive conditions in Victoria, Australia. BMC Health Serv Res 2012; 12:475..

Moreover, there is great influence of the structuration of health services in each territory on hospitalizations, with highlight to the organization of the ambulatory service, composition of health teams (which have as an important challenge the establishment of doctors in the locations), qualification of professionals, employment ties, among other elements linked to the structural dimension²³23. Elias E, Magajenski F. A Atenção Primária à Saúde no Sul de Santa Catarina: uma análise das internações por condições sensíveis à atenção ambulatorial, no período de 1999 a 2004. Rev Bras Epidemiol 2008;11(4):633-647.. Therefore, the analysis is deemed necessary, not only of the results of the assistance, through hospitalizations, for instance, but also of the working process and the structure professionals have to implement their actions.

When it comes to the state of Paraná, the correlation between FHS coverage and rates of hospitalization for diabetes was nearly significant (p=0.061), in an inverse way and with strong intensity. However, in Paranaguá, Metropolitan, Foz do Iguaçu and Umuarama HDs, the correlation analysis suggests that the increase in FHS coverage may have influenced the reduction in rates of hospitalization for diabetes.

Consonantly, a study conducted in the south of Santa Catarina observed that hospitalizations for diabetes presented an upward trend in the population with basic ambulatory care rated as adequate²³23. Elias E, Magajenski F. A Atenção Primária à Saúde no Sul de Santa Catarina: uma análise das internações por condições sensíveis à atenção ambulatorial, no período de 1999 a 2004. Rev Bras Epidemiol 2008;11(4):633-647.. Other studies also observed inverse correlation between PHC coverage and hospitalization for diabetes⁸8. Robbins JM, Valdmanis VG, Webb DA. Do public health clinics reduce rehospitalizations?: the urban diabetes study. J Health Care Poor Underserved 2008; 19(2):562-573.^,1717. Campos AZ, Theme-filha MM. Internações por condições sensíveis à atenção primária em Campo Grande, Mato Grosso do Sul, Brasil, 2000 a 2009. Cad Saude Publica 2012; 28(5):845-855.. However, this question is pondered, stressing that, even with free access to ambulatory services for underprivileged populations, the latter still present an excessive number of HACSC¹⁰10. Booth GL, Hux JE. Relationship between avoidable hospitalizations for diabetes mellitus and income level. Archiv Intern Med 2003; 163(1):101-106..

In the case in which no correlation was found, it can be inferred that the FHS, which, strictly speaking, should lead to a reduction in hospitalizations for diabetes, may still present difficulties in the implementation of resolutive actions about diabetes, although it is considered the most sensitive one among the ACSC, because the obtainment of positive results requires minimal organization from the health service. A study conducted in Rio Grande do Sul also identified higher rates in regions with greater concentration of small cities, and attributes this profile to the fact that hospitals in said cities use their maximum installed capacity. For this reason, they admit more easily cases which would not necessarily need this level of assistance, in order to obtain resources according to the number of hospitalizations performed²⁴24. Dias-da-Costa JS, Buttenbender DC, Hoefel AL, Souza LL. Hospitalizações por condições sensíveis à atenção primária nos municípios em gestão plena do sistema no Estado do Rio Grande do Sul, Brasil. Cad Saude Publica 2010; 26(2):358-364..

In this sense, another study, conducted in Rio Grande do Sul as well, identified strong and positive correlation between HACSC and FHS coverage in municipalities with small-size hospitals, differently from those municipalities which did not have small-size hospitals, indicating lower rates of HACSC in medium-size cities and big centers²⁵25. Soleiman AP. Análise da relação entre internações por condições sensíveis à atenção primária, hospitais de pequeno porte e estratégia saúde da família no âmbito de uma regional de saúde [tese]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2013..

It is believed that the same principle can be attributed to HDs where there was direct correlation with FHS coverage. That is, “unnecessary” hospitalizations may have influenced this correlation. In this way, the coordination power of PHC over the flow of health system users ceases to impact the occupation of hospital beds, and begins to comply with a certain accounting logics that opposes to the model of reorganization of assistance and reaffirms the healing perspective with which health services are impregnated.

Furthermore, it should be taken into consideration that the rise in hospitalizations in said HDs, concomitant with that of the FHS coverage, may be linked to improved access, the system's better capacity for diagnosis, and empty hospital beds¹⁷17. Campos AZ, Theme-filha MM. Internações por condições sensíveis à atenção primária em Campo Grande, Mato Grosso do Sul, Brasil, 2000 a 2009. Cad Saude Publica 2012; 28(5):845-855.. Therefore, in the case of chronic conditions, the demand for longer care time, the influence of morbidity profile, the search for health services, and the population's lifestyle can restrict the assessment of the impact of the FHS on such conditions¹⁷17. Campos AZ, Theme-filha MM. Internações por condições sensíveis à atenção primária em Campo Grande, Mato Grosso do Sul, Brasil, 2000 a 2009. Cad Saude Publica 2012; 28(5):845-855..

Although the population coverage of the service is an essential component of the health system's problem-solving ability, the high HACSC rates man indicate poor access to services offered by PHC or the offering of low-quality services. A systematic review of the literature found that PHC deficiencies were associated with HACSC in different countries, whereas the continuity of care, the performance of the multiprofessional team and the population served by said team were associated with lower likelihood of hospitalization for ACSC²⁶26. Nedel FB, Facchini LA, Martín M, Navarro A. Características da atenção básica associadas ao risco de internar por condições sensíveis à atenção primária: revisão sistemática da literatura. Epidemiologia e Serviços de Saúde 2010; 19(1):61-75..

The regionalized analysis of diabetes trends and correlations with the FHS can provide subsidizes of epidemiological character to the planning of local interventions. In this way, it is possible to meet – besides population needs – municipal agreements with the Ministry of Health, which include, among other indicators, the rate of hospitalization for diabetes and complications among people aged 30 years or over, as well as the focus on the 30-59 years old age group, as a strategy to avoid the aforementioned events, since the longer the diagnosis time, the smaller the success of interventions²⁶26. Nedel FB, Facchini LA, Martín M, Navarro A. Características da atenção básica associadas ao risco de internar por condições sensíveis à atenção primária: revisão sistemática da literatura. Epidemiologia e Serviços de Saúde 2010; 19(1):61-75..

In this line, a study about people aged between 30 and 59 years old, hospitalized due to diabetes or its complications, conducted in Joinville, Santa Catarina, indicates some characteristics of health profile, use of health services and compliance with therapy, which may be associated with hospitalizations, such as type-2 diabetes with evolution time equal or greater than 10 years, comorbidities, re-hospitalizations, non-attendance to PHC consultations in the last 12 months, discrepancies in appointed consultations, difficulty of access to specialized consultations, flaws in the performance of drug therapy and low compliance with health practices, especially the regular practice of exercises²⁷27. Artilheiro MMVSA, Franco SC, Schulz VC, Coelho CC. Quem são e como são tratados os pacientes que internam por diabetes mellitus no SUS? Saúde Debate 2014; 38(1):210-224..

As options, strategies coming from clinical management and based on risk stratification and biopsychosocial factors of the population, such as operative groups and supported self-care, can be decisive in the gaining of self-efficacy by PHC users and, consequently, in the achievement of lower hospitalization rates²⁸28. Mendes EV. O cuidado das condições crônicas na Atenção Primária à Saúde: o imperativo da consolidação da Estratégia Saúde da Família. Brasília: OPAS; 2012. The implementation of multidisciplinary intervention programs at basic health units can promote the adoption of health practices among people with diabetes, as pointed by a study conducted in a municipality in northwestern Paraná²⁹29. Carolino ID, Molena-Fernandes CA, Tasca RS. Risk factors in patients with type 2 diabetes mellitus. Rev Latino-Am Enferm 2008; 16(2):238-244.. In general terms, PHC must be associated with the improvement in decision-making as to drug prescriptions, to additional exam requests and to other assessments, including improvement in glycemic control, decrease in consultations with specialists and in search for emergency services³⁰30. Batista SRR, Jardim PCB, Sousa ALL, Salgado CM. Hospitalizações por condições cardiovasculares sensíveis à atenção primária em municípios goianos. Rev Saude Publica 2012; 46(1):34-34..

The results of the present study can indicate stalemates in the organization of the health system at local and regional levels, that is, for each HD and the state of Paraná. Concerning diabetes, this study may contain subsidizes for the surveillance and operationalization of health planning, focusing on the capacity of organization of the health system PHC has. It is worth stressing methodological limitations of the present investigation. First, the use of data from secondary databases, which may present problems concerning the range and quality of information recorded and conveyed by the system and, for this reason, the use of information for epidemiological purposes requires caution.

Additionally, the absence of demographic and socioeconomic data may represent a limitation as well, as they can constitute important information to be associated with hospital morbidity deriving from diabetes. Thus, as a recommendation, further investigations should perform an analysis of hospitalizations, with control of confusion factors represented by demographic and socioeconomic variables, as well as variables concerning local health services, which may require the crossing of data from different sources. Finally, the fact that the information system does not discriminate what individuals are or are not assisted by the FHS, that it does not consider private hospitalizations and does not allow for the identification of re-hospitalizations, constitutes limitations of this study. Therefore, the correlation coefficients evidenced cannot be regarded as consequences derived exclusively from FHS interventions, because confusion variables have not been controlled.

References

Publication Dates

History