Abstract

This study compared standardised rates of hospitalisations due to ambulatory care sensitive conditions (ACSCs) in Brazil’s Federal District from 2009 to 2018, as compared with those for selected state capitals, age groups and admissions groups. This ecological study used secondary data drawn from Hospital Information System microdata for the study period, during which, in the Federal District, the proportion of such admissions among 50-59 and 60-69 year olds declined, while those among children and adolescents held stable. Meanwhile, rates did not decrease in the ≤ 20 year age groups, a priority population in PHC, which may suggest that this population encountered barriers to access. The results showed that the expected reduction in the proportion of such admissions has not occurred, because coverage by Family Health Teams has been expanded only recently.

Keywords
Primary health care; Hospitalisations due to ambulatory care sensitive conditions

Introduction

Primary Health Care (PHC) is interpreted in various manners, which can be explained by the manner in which it originated and has evolved in practice in health systems, by the ambiguity of some of its formal definitions as established in international forums and by the indiscriminate use of the term by some schools of thought in public health¹1. Mendes EV. A construção social da Atenção Primária à Saúde . Brasília: Conass; 2015. .

That said, there are basically three main interpretations: PHC as selective primary care, understood as a specific programme offering a set of simple, low-cost technologies destined for poor populations and regions; PHC as the primary level of the health care system; and PHC as a strategy for organising the health system¹1. Mendes EV. A construção social da Atenção Primária à Saúde . Brasília: Conass; 2015. .

In Brazil, PHC has been considered synonymous with basic care since publication of the 2011 National Basic Care Policy (PNAB) and then again in the 2017 PNAB²2. Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização daAtenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set. . From the outset, it was conceived as the gateway to the health system and today plays a leading role in Health Care Networks as the centre of communication and, in setting up the networks, as the organiser and coordinator of care. For these purposes, it is structured by seven attributes: first contact, comprehensiveness, continuity, coordination, family-centred, family approach and community-oriented³3. Brasil. Ministério da Saúde. Portaria n. 4.279, 30 dezembro 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dez. .

There is evidence from Brazil and internationally that strong PHC is the model of care best suited to responding to the current epidemiological and demographic transition⁴4. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3):457-502.

5. Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Aff (Millwood) 2013; 32(4):686-694. - ⁶6. Kruk ME, Porignon D, Rockers PC, Van Lerberghe W. Contribution of primary care to health and health systems in low- and middle-income countries. Soc Sci Med 2010; 70(6):904-911. . In Brazil, the Family Health Strategy ( Estratégia de Saúde da Família , ESF) is considered a priority strategy for expanding, establishing and informing basic care, and is producing important results as shown in indicators of health, efficiency and equity⁷7. Dourado I, Medina MG, Aquino R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). Int J Equity Health 2016; 15(1):151.

8. Guanais FC. The Combined Effects of the Expansion of Primary Health Care and Conditional Cash Transfers on Infant Mortality in Brazil, 1998–2010. Am J Public Health 2015; 105(No. S4):S593-S599.

9. Cabral NL, Franco S, Longo A, Moro C, Buss TA, Collares D, Werlich R, Dadan DD, Fissmer CS, Aragão A, Ferst P, Palharini FG, Eluf-Neto J, Fonseca LA, Whiteley WN, Gonçalves AR. The Brazilian Family Health Program and secondary stroke and myocardial infarction prevention: a 6-year cohort study. Am J Public Health 2012; 102(12):e90-95. - ¹⁰10. Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde em Debate 2018; 42(n. esp. 1):18-37. .

Brazil-wide coverage by the ESF is currently estimated at 64.61% and is greatest in the Northeast Region (80.11%)¹¹11. Brasil. Ministério da Saúde (MS). Sala de Situação de Saúde . Brasília: MS; 2018. [acessado 2018 Maio 26]. Disponível em: http:// https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml
https://egestorab.saude.gov.br/paginas/a... . The Federal District has invested in changing the model of care so that PHC will be grounded completely on the ESF in the terms of the National Basic Care Policy and the Federal District Health Council Resolution. In 2017 two administrative orders published in the Federal District established first a Primary Health Care Policy¹²12. Distrito Federal. Secretaria de Estado de Saúde. Portaria N° 77, de 14 de fevereiro de 2017. Estabelece a Política de Atenção Primária à Saúde do Distrito Federal. Diário Oficial do Distrito Federal 2017; 15 fev. and then the process of conversion of PHC to the ESF model¹³13. Distrito Federal. Secretaria de Estado de Saúde. Portaria N° 78, de 14 de fevereiro de 2017. Regulamenta o art. 51 da Portaria nº 77. Diário Oficial do Distrito Federal 2017; 15 fev. . The state health department (SES/DF) reports that coverage increased from 24.7% in 2015 to 69.10% in 2018¹⁴14. Distrito Federal. Secretaria de Estado da Saúde. Brasília; 2018. [acessado 2018 Maio 26]. Disponível em: http://saude.def.gov.br.
http://saude.def.gov.br... .

One of the indicators used worldwide to assess PHC indirectly is hospitalisations due to ambulatory care sensitive conditions (HACSCs). The conceptual framework for constructing this indicator followed the model proposed by Caminal-Homar & Casanova-Matutano and was adapted to Brazilian conditions. Its underlying principle is that, for certain health conditions, timely, quality PHC can avert hospitalisation or reduce its frequency¹⁵15. Alfradique ME, Bonolo PF, Dourado I, Costa–Lima MF, Macinko J, Mendonça CS, Oliveira VB, Sampaio LFR, Simoni C, Turci MA. 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. .

The process of constructing the indicator involved criteria formulated from existing lists in some state health departments, a literature review of international studies, consensus meetings among researchers, policymakers and experts on the subject, and public consultation. The Brazilian List of HACSCs, comprising 19 groups of causes and diagnoses identified by ICD 10 codes, was then published in the form of an annex to Administrative Order SAS No. 221, of 17 April 2008¹⁶16. Brasil. Ministério da Saúde (MS). Portaria nº 221, de 17 abril de 2008. Publica em forma do anexo a lista brasileira de internações por condições sensíveis à atenção primária. Diário Oficial da União 2008; 21 set. .

A number of studies conducted in Brazil have adopted HACSCs for evaluating PHC access and effectiveness. Despite certain limitations in using this indicator, It has pointed to the importance of PHC in reducing such hospital admissions¹⁷17. Macinko J, Dourado I, Aquino R, Bonolo PF, Lima-Costa MF, Medina MG, Mota E, Oliveira VB, Turci MA. Major expansion of primary care in Brazil linked to decline in unnecessary hospitalization. Health Aff (Millwood) 2010; 29(12):2149-2160

18. Bastos ML, Menzies D, Hone T, Dehghani K, Trajman A. The impact of the Brazilian family health strategy on selected primary care sensitive conditions: A systematic review. PLoSOne 2017;12(8):e0182336. - ¹⁹19. Tuesta AA, Santos LMP, Iturri JA. Processos e desafios da interação entre pesquisa e política na perspectiva dos pesquisadores. Cien Saude Colet 2018; 23(1):7-15. .

There is disagreement in the literature, however, as to the effects of expanding Primary Health Care coverage on reducing HACSCs. Campos & Theme-Filha²⁰20. 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. , for example, observed an inverse correlation between ESF coverage and HACSC coefficients in the municipality of Campo Grande. Mendonça et al.²¹21. Mendonça CS, Harzheim E, Duncan BB, Nunes LN, Leyh W. Trends in hospitalizations for primary care sensitive conditions following the implementation of Family Health Teams in Belo Horizonte, Brazil. Health Policy Plan 2012; 27(4):348-355. , examined the trend in Belo Horizonte, finding 74.5% ESF coverage and significant reduction in HACSCs. Morimoto & Dias da Costa²²22. Morimoto T, Dias da Costa JS. Internações por condições sensíveis à atenção primária, gastos com saúde e Estratégia Saúde da Família: uma análise de tendência. Cien Saude Colet 2017; 22(3):891-900. , meanwhile, did not find this negative correlation and thus suggested that other factors may be associated with these results.

At present the Federal District is converting its model of care and considering expanding ESF coverage, making this an opportune moment for studies and research, considering that evidence based policymaking can produce social and economic impacts, as well as equity and health benefits.

In that light, the purpose of this study is to describe the change over time in hospital admissions for conditions amenable to Primary Health Care, comparing the Federal District with other selected state capitals.

Material and Methods

This ecological study used secondary data drawn from the number of hospital admissions in Brazil’s Single Health System ( Sistema Único de Saúde , SUS) recorded in the Hospital Information System ( Sistema de Informações Hospitalares , SIH-SUS). Data were collected from the system by a census study of Type-1 Short-Term Hospital Admission Authorisation (AIH tipo 1) records and were grouped by municipality of residence. These records are in the public domain on the web site of the Executive Secretariat of the Ministry of Health’s data processing department (DATASUS), and are available month by month in the form of “reduced” files (microdata in RD files). The study period was from 2009 to 2018, totalling 3,240 files (12 per year x 10 years x 27 states). These were read using SAS System software with statistics programming and macros, thus creating the variable “number of hospitalisations due to ambulatory care sensitive conditions (HACSCs)”, as defined by Alfradique et al.¹⁵15. Alfradique ME, Bonolo PF, Dourado I, Costa–Lima MF, Macinko J, Mendonça CS, Oliveira VB, Sampaio LFR, Simoni C, Turci MA. 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. .

HACSC rates were calculated and standardised by the direct method (age group). The data of the 2010 IBGE Population Census were used for standard population. These rates were then compared with those for “Not HACSCs” in selected geographical areas and also for the 20 groups that make up HACSCs. For that purpose, it was decided to select the state capitals with the largest populations in Brazil’s South and Southeast regions.

Unfortunately, the Ministry of Health did not begin publishing microdata for Brasilia separately from its satellite towns until 2012, thus precluding the historical comparisons proposed here, which would have considered only the city of Brasilia.

Results and Discussion

The Federal District: age profile and groups of hospitalisations due to ambulatory care sensitive conditions

Stratification of HACSCs by age group highlighted the large proportion of such admissions among children up to nine years of age, who represented around 20% of total admissions in the Federal District. From 2009 to 2018, the relative share of the 50-59 and 60-69 year age groups declined, while the proportion of such admissions among children and adolescents held stable, suggesting that in the last 10 years efforts to expand primary care have had more effect in reducing admissions among young adults, concentrated in the 40-59 year age group. On the other hand, the absence of any reduction among the under 20s, who are a priority population for PHC, may suggest that this population encounters barriers to access to PHC in the Federal District ( Table 1 ), which may have to do with the working hours of primary health facilities there.

Studies of HACSCs in Brazil, as in other countries that use the indicator, vary greatly in methodology, in control variables used, especially the socio-demographic variables, and in the groups of diseases included. While, on the one hand, percentage rates of HACSCs in the state capitals are stable at around 10 to 15% of total admissions, an examination of the groups that make up HACSCs reveals regional inequalities that may reflect the stage of health system organisation and PHC’s centrality or otherwise to the system²³23. Soranz D, Pinto LF, Penna GO. Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2016; 21(5):1327-1338. , ²⁴24. Pinto LF, Giovanella L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Cien Saude Colet 2018; 23(6):1903-1914. .

On examining the groups into which HACSCs can be subdivided ( Table 2 ), municipal-based studies, mainly in the South and Southeast regions, of the under-20s, find that there has been a decrease in admissions connected with avoidable and immunisable conditions, nutritional deficiencies and anaemia, and those relating to the perinatal period and parasitic infectious diseases, such as gastroenteritis. Non-reductions (stability or increases in the time analyses) were found in admissions for bronchopneumonia and asthma. However, studies of children under five years old in municipalities in the states of Piauí²⁵25. Barreto JOM, Nery IS, Costa MSC. Estratégia Saúde da Família e internações hospitalares em menores de 5 anos no Piauí, Brasil. Cad Saude Publica 2012; 28(3):515-526. and Pernambuco²⁶26. Carvalho SC, Mota E, Dourado I, Aquino R, Teles C, Medina MG. Hospitalizations of children due to primary health care sensitive conditions in Pernambuco State , Northeast Brazil. Cad Saude Publica 2015; 31(4):744-754. and of Yanomami indigenous children in Boa Vista (Roraima)²⁷27. Caldart RV, Marrero L, Basta PC, Orellana JDY. Fatores associados à pneumonia em crianças Yanomami internadas por condições sensíveis à atenção primária na região norte do Brasil. Cien Saude Colet 2016; 21(5):1597-1606. have found gastroenteritis to be the most prevalent cause of admissions, along with pneumonia.

In the Federal District, among the adult and elderly population, the groups in which reductions were observed were cardiovascular diseases such as hypertension, cardiac insufficiency and angina, while some studies found increases in the diabetes mellitus and stroke groups. The most prevalent infectious diseases causing admissions were bronchopneumonia, gastroenteritis and infections of the kidney and urinary tract ( Table 2 ).

The Federal District compared with other state capitals in Brazil

A consolidated analysis for the period from 2009 to 2018 in certain selected state capitals and the Federal District revealed that Florianópolis and Curitiba (cities with high primary care coverage) historically have returned rates of hospital admissions for conditions amenable to primary care close to 10%, which were not attained by the city of Rio de Janeiro until 2013, as a result of the process of PHC expansion implemented there, as described by Soranz et al.²³23. Soranz D, Pinto LF, Penna GO. Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2016; 21(5):1327-1338. . The Federal District was one of the worst performing states in the historical series examined, starting at values of around 13% and tending to stabilise at that level. Overall performance was similar to DF when statistics for the set of 27 state capitals was considered ( Table 3 ).

The statistical treatment used in order to reduce data analysis bias in comparing standardised rates was to compare HACSCs vs Non-HACSCs; after all, reductions in HACSC rates may have occurred as a result of overall reductions in admissions in Brazil.

In this case, when variations in standardised rates of HACSCs vs Non-HACSCs for the period from 2009 to 2018 are examined ( Table 4 ), differences can be seen over the course of the decade: (a) in Brazil overall, the reductions in standardised HACSC rates were far greater (-26.6%) than in non-HACSC rates (-12.4%); (b) Rio de Janeiro municipality stands out as where the reduction in standardised HACSC rates was greatest (-13.4%), as compared with non-HACSC rates (-2.0%); (c) in the Federal District, the decrease was similar in both statistics (-15.2% and -13.7%). When these variations were calculated for the 2013-2016 municipal electoral cycle, the state capitals of the Southeast Region and the Federal District stand out as having the largest reductions in total standardised HACSC rates ( Graph 1 ).

Limitations of the study

This study’s internal validity is limited by the fact that both the admitting diagnosis and the classification of diseases by CID-10 codes at the time the hospital admission authorisation ( Autorização de Internação Hospitalar , AIH) records were completed are influenced by the doctor’s clinical knowledge and other organisational factors at the hospital facility, as also reported by Rehem et al.²⁸28. Rehem TCMSB, Oliveira MRF, Ciosak SI, Egry EY. Record of hospitalizations for ambulatory care sensitive conditions: validation of the hospital information system. Rev. Latino-Am. Enfermagem 2013; 21(5):1159-1164. . However, this is the only major data base of microdata in the Hospital Information System (SIH-SUS) with consolidated historical series on Brazil’s national public health system. Also, coverage by private health insurance in the state capitals diverges widely from the situation in other parts of the country, and part of the admissions in state capitals, which occur in the private sector, are not contemplated in the analysis conducted here.

Another aspect which is often mentioned in studies of HACSCs²⁴24. Pinto LF, Giovanella L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Cien Saude Colet 2018; 23(6):1903-1914. is the proportional analysis of these groups, given that diseases compete for a finite number of beds (smaller than the demand), and as a result a proportional reduction in one group may in fact reflect a proportional increase in occurrences of competing conditions.

Lastly, another limitation of the study is the fact that the SIH-SUS does not unequivocally link which people are or are not covered by the Family Health Strategy or traditional primary care, just as other factors, such as disease prevalence, disease burden, multi-morbidity, the clinical practice of doctors and multi-professional teams, which could potentially explain the hospital admissions outcome, were not included in the analysis and could have affected these results.

Conclusion

The findings of this study are evidence that the Federal District has not yet displayed the decreasing proportion of hospital admissions for conditions amenable to primary care which was expected to result from the expansion of primary care observed since 2016. It is hoped that in coming years, other studies will examine the historical series analysed here and measure the related medium- and long-term effects.

However, a considerable downward trend was observed in the proportion of HACSCs in the 40-69 year age group in the Federal District ( Table 1 ), suggesting that the adult health measures taken in the past ten years are helping to improve the situation. Although it is impossible to isolate the effects of primary health care, it is quite plausible that the reduction in HACSCs in this specific age group are connected with increased PHC coverage in the Federal District, especially in the monitoring of chronic conditions such as hypertension and diabetes, improved diagnosis, greater ease of access to medicines and coordination of care by the Family Health Teams.

The actions and procedures that are to be incorporated into the portfolio of Primary Health Care services in the Federal District to address chronic conditions are multiple and multi-professional. Stratification for risk and vulnerability, supply of collective care and continuous care, supported self-care, complex clinical case management, tele-healthcare support and planned home care, particularly following hospital discharge, prevent re-admissions and reduce costs²⁹29. Batista JAL, Furtado MV, Katz N, Agostinho MR, Neto BS, Harzheim E, Polanczyk CA. Telemedicine-supported transition of stable coronary artery disease patients from tertiary to primary health care facilities: protocol for a randomized non-inferiority trial. BMC Health Services Research 2016; 16:227. , ³⁰30. Soranz D. Reforma da atenção primaria em saúde na cidade do Rio de Janeiro (2009-2016):uma avaliação de estrutura, processo e resultado [tese]. Rio de Janeiro: Fiocruz; 2017. .

The factors with which primary health care services work to reduce health conditions are different for each type of condition. On the one hand, reducing admissions for chronic conditions depends on greater access to PHC doctors and on the type of medicine practiced, as measured by clinical care management technologies, such as adherence to protocols, continuity of care and collaboration among different professions in PHC. As regards acute and infectious conditions, on the other hand, the teams’ endeavour is to assure that interventions of proven effectiveness and efficiency – for example, increasing water intake among the elderly, so as to avert admissions for dehydration and kidney infections, and increasing vaccination coverage among the frail elderly, so as to prevent complications from bacterial pneumonias – are being conducted appropriately and reaching the most vulnerable population groups. Monitoring of such admissions, by population group, group of diseases and regions in a given municipality, can help in setting health service investment priorities, with a view to maintaining rates at acceptable levels associated with expansion of effective primary health care.

References

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History