Abstracts

INTRODUCTION

In the 1980s, with the implementation of the Unified Health System (SUS), important changes happened in the Brazilian health system, which was then characterized by a curative, medical-welfare and hospitalocentric system that mainly cared for the urban population and paid workers, therefore, leaving large population contingents unattended, including people living in rural areas, unemployed people and professionals without an adequate work register¹1 . Vasconcelos CM, Pasche DF. O Sistema Único de Saúde. In: Campos GWS, Minayo, MCS, Akerman M, Drumond JM, Carvalho YM. (Org.). Tratado de Saúde Coletiva. Rio de Janeiro e São Paulo: Fiocruz/Hucitec; 2006.. The Brazilian Sanitary Reform proposed new ways of producing health by prioritizing primary health care, which resulted in more access for the users, improved health indicators and reduced costs of care²2 . Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002..

In 1994, the Family Health Program was established, being currently entitled Family Health Strategy (FHS), which aims at reorganizing care practices focusing on basic health care³3 . Brasil. Ministério da Saúde. Saúde da Família: Uma estratégia para a reorientação do modelo assistencial. Brasília: Ministério da Saúde; 1998.. FHS includes health promotion actions, prevention of diseases and early diagnosis, especially of more prevalent pathologies and conditions that can be handled in primary care⁴4 . Fernandes LCL, Bertoldi AD, Barros AJD. Utilização dos serviços de saúde pela população coberta pela Estratégia de Saúde da Família. Rev Saúde Pública 2009; 43(4): 595-603..

In Brazil, FHS needs to work on evaluation processes, including the field of health work⁵ 5 . Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002. 189 p.and the impact caused on morbidity and mortality rates of the population⁶6 . Gil CRR. Formação de recursos humanos em saúde da família: paradoxos e perspectivas. Cad. Saúde Pública 2005; 21(2): 490-8., which enable the organization of their assistance actions and practices⁷7 . Viana ALA, Rocha JLY, Elias PE, Ibañez N, Novaes MHD. Modelos de atenção básica nos grandes municípios paulistas: efetividade, eficácia, sustentabilidade e governabilidade. Ciênc Saúde Coletiva 2006; 11(3): 577-606. ^{, 8}8 . Roncalli AG, Lima KC. Impacto do Programa Saúde da Família sobre indicadores de saúde da criança em municípios de grande porte da região Nordeste do Brasil. Ciênc Saúde Coletiva 2006; 11(3): 713-24..

Studies in several countries contributed with the identification of markers that assist the evaluation of health systems, among which are hospitalizations caused by Ambulatory Care Sensitive Conditions (ACSC). The ACSCs are morbidities that can be dealt with in primary care, thus preventing the aggravation of the clinical condition and unnecessary hospitalizations; besides, they constitute an indicator that measures the quality and the resoluteness of FHS⁹9 . Marmot M. Health in an unequal world. Lancet 2006; 368(9552): 2081-94.

10 . The United Nations Children's Fund (UNICEF). Countdown to 2015: maternal, newborn and child survival. Tracking progress in maternal, neonatal and child survival: the 2008 report. New York, NY: UNICEF; 2008.

11 . Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004; 14(3): 246-51. ^{- 12}12 . 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 Saúde Pública 2009; 25(6): 1337-49..

In Brazil, the hospitalization rate is of 525 per 10 thousand inhabitants, and 27% of them are caused by preventable conditions. Among the conditions that lead to hospitalization for ACSCs, pre-existing and transmissible diseases, heart and respiratory conditions, as well as diseases of the circulatory system and those related to prenatal and labor periods are prevalent¹²12 . 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 Saúde Pública 2009; 25(6): 1337-49..

The reduced number of hospitalizations due to ACSC is one of the markers of the effectiveness of FHS¹³13 . Nedel FB, Facchini LA, Marín-Mateo M, Vieira LAS, Thumé E. Desempenho do ESF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica à saúde. Ciênc Saúde Coletiva 2006; 11: 669-81. ^{, 14}14 . Elias E, Magajewski 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): 633-47., based on the fact that hospitalized people were not adequately cared for in the primary level, thus leading to the aggravation of their clinical condition¹⁰10 . The United Nations Children's Fund (UNICEF). Countdown to 2015: maternal, newborn and child survival. Tracking progress in maternal, neonatal and child survival: the 2008 report. New York, NY: UNICEF; 2008.

11 . Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004; 14(3): 246-51. ^{- 12}12 . 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 Saúde Pública 2009; 25(6): 1337-49..

It is estimated that the implementation of public policies addressed to primary care in all of the Brazilian states in the past few years has contributed with the reduction of hospitalizations. The objective of this study was to assess the relationship between hospitalizations for ACSC and the population coverage of FHS in the Brazilian Federation Units in the past decade.

METHODS

This is an ecological study that analyzed the relationship between hospitalizations for ACSC and the population coverage of FHS in the Brazilian Federation Units in the historic series of 1998 to 2006. The ecological model was considered to be appropriate to assess the results of a health public policy comprehending large population groups¹⁵15 . Morgenstern H. Ecologic studies. In: Rothman KJ, Greenland S. Modern epidemiology. Philadelphia: Lippincott Williams & Wilkins; 1998. p. 459-80., so it is difficult to conduct this type of evaluation using only the individual perspective.

Secondary data referring to hospitalizations for ACSC were collected in the Primary Care Information System, in the electronic address of DATASUS (www.datasus.gov.br), from the Ministry of Health. Hospitalizations were selected from the Brazilian list of ACSC¹⁶16 . Brasil. Ministério da Saúde. Departamento de Atenção Básica. O?cina de trabalho para elaboração de uma lista brasileira de hospitalização por condições sensíveis à atenção primária. Belo Horizonte, MG; 2005., elaborated by the Ministry of Health in 2005 (Table 1), which identifies conditions that are sensitive to primary health care¹¹11 . Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004; 14(3): 246-51.. There are 20 groups of causes including pathologies and conditions belonging to each chapter of the ICD-10.

Coefficients of hospitalization for ACSC were developed, proportionally to 10 thousand inhabitants for Brazil and the Federation Units in the analyzed period. In the numerator, there was the total of hospitalizations due to avoidable causes and, in the denominator, the estimated population for each year of the historic series.

The number of FHS teams in Brazil and in the Federation Units was obtained in the website of the Primary Care Department, from the Ministry of Health (http://dab.saude.gov.br/). The ratio of inhabitants per FHS was calculated by dividing the total number of the population by the number of teams in the studied period.

The population coverage of FHS was calculated by estimating 3,500 people for each team. Firstly, the total number of assisted people was obtained, by multiplying the number of FHS teams in each Federation Unit by 3,500. Then, the result was divided by the total population of each State, obtaining the percentage of population coverage for each Brazilian Federation Unit.

The statistical analysis was conducted with the software Statistical Package for the Social Sciences (SPSS), version 11.5. The relationship between FHS coverage and hospitalizations for ACSC was estimated with the Pearson correlation teste, and the simple linear regression was used to calculate the R²2 . Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002. value and confidence intervals for β values. The variables presented normal distribution and the adaptation to the regression model was tested by the residue analysis. The dependent variable was the hospitalization rate for ACSC per 10 thousand inhabitants, and the independent variable was the percentage of FHS population coverage in Brazil and in the Federation Units between 1998 and 2006.

This study has no conflict of interests and the research project was approved by the Research Ethics Committee of Universidade de Cruz Alta (Unicruz).

RESULTS

In Brazil, the number of FHS teams went from 3,062 in 1998, to 26,364, in 2006, representing a 861% increase. The ratio inhabitants per FHS reduced from 52,838 to 7,084 people assisted by FHS in the studied period, while the population coverage increased 748%. Hospitalizations for ACSC reduced 17% (Table 2).

Table 3 presents data referring to the number of teams, population coverage per FHS and hospitalization rate for ACSC in the Federation Unit in the first and in the last analyzed year. The 26 Brazilian States presented increasing number of teams and FHS population coverage and, in 88.4% of the cases (23 Federation Units), there were reduced hospitalization rates for ACSC. Only three States in the North region presented increasing hospitalization rates: Acre, Amapá and Amazonas.

Table 4 presents the Pearson correlation values between the percentage of FHS coverage and the coefficient of hospitalizations for ACSC proportionally to 10 thousand inhabitants, according to the Federation Units. The bivariate analysis showed strong negative correlation between the FHS population coverage and avoidable hospitalizations in Brazil (r = -0.867; p < 0.01). In 38.4% (10 States), correlation was statistically significant and negative (p < 0.05; r > -0.7), thus showing that the increasing FHS coverage was associated with the reduced number of hospitalizations for ACSC. In 42.3% (13 States), there was a reduction in hospitalization rates, however, no statistically significant association. In only three States of the North region (Acre, Amazonas and Pará), hospitalization rates increased, and there was a positive correlation (p < 0.05) between FHS coverage and hospitalization for ACSC.

Table 5 presents the results of simple linear regression, and the outcome were hospitalizations for ACSC. It was possible to observe strong association between the more extensive FHS coverage and the reduced number of avoidable hospitalizations in Brazil (β = -8.78; p < 0.01).

DISCUSSION

The increasing FHS population coverage in Brazil was a gradual process, and, in the first four years of existence (1994-1998), it reached 6% of the population. In 1999, there were 4,114 FHS teams distributed in 30% of the cities, comprehending 14 million people and 9% of the country's population¹¹11 . Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004; 14(3): 246-51.. In 2006, there were 26,364 FHS teams, reaching 49% of the population coverage.

The process of FHS implantation in Brazil was carried out with difficulties related to the application of financial resources, lack of professionals and lack of commitment from many cities with the primary care proposal⁸8 . Roncalli AG, Lima KC. Impacto do Programa Saúde da Família sobre indicadores de saúde da criança em municípios de grande porte da região Nordeste do Brasil. Ciênc Saúde Coletiva 2006; 11(3): 713-24. ^{, 13}13 . Nedel FB, Facchini LA, Marín-Mateo M, Vieira LAS, Thumé E. Desempenho do ESF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica à saúde. Ciênc Saúde Coletiva 2006; 11: 669-81. ^{, 17}17 . Iezzoni LI. Assessing quality using administrative data. Ann Intern Med 1997; 127(82): 666-74.. Financing related to population coverage led to the faster expansion of FHS in smaller cities¹⁷17 . Iezzoni LI. Assessing quality using administrative data. Ann Intern Med 1997; 127(82): 666-74., but there were difficulties and insufficient coverage in large urban centers¹⁸18 . Machado CV, Lima LD, Viana LS. Configuração da atenção básica e do Programa Saúde da Família em grandes municípios do Rio de Janeiro, Brasil. Cad Saúde Pública 2008; 24 Suppl 1: 42-57.. Besides, the heterogeneity of Brazilian States, especially concerning dimension, economic resources, access, availability of professionals and investments, and the political implication, also made it difficult to implement the FHS in Brazil¹³13 . Nedel FB, Facchini LA, Marín-Mateo M, Vieira LAS, Thumé E. Desempenho do ESF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica à saúde. Ciênc Saúde Coletiva 2006; 11: 669-81..

Brazilian studies indicate that FHS has presented successful results¹⁹19 . Macinko J, Guanais FC, Souza MFM. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60(1): 13-9.

20 . Magan P, Otero A, Alberquilla A, Ribera JM. Geographic variations in avoidable hospitalizations in the elderly, in a health system with universal coverage. BMC Health Serv Res 2008; 8: 42. ^{- 21}21 . Ceccon RF, Borges DO, Paes LG, Klafke JZ, Viecili PRN. Mortalidade por doenças circulatórias e evolução da saúde da família no brasil: um estudo ecológico. Ciênc Saúde Coletiva 2013; 18(5): 1411-6., thus contributing with reduced hospitalization rates for ACSC¹⁹19 . Macinko J, Guanais FC, Souza MFM. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60(1): 13-9. ^{, 22}22 . Campos AZ, Theme-Filha MM. Internações por condições sensíveis à atenção primária em Campo Grande, Mato Grosso do Sul, Brasil, 2000 a 2009. Cad. Saúde Pública 2012; 28(5): 845-55., even though they are still high in the country. In this study, the declining number of hospitalizations for ACSC in brazil became clear, thus corroborating investigations conducted in other regions and countries, in which it was possible to observe the relationship between the reduced number of hospitalizations for ACSC and the increasing primary care¹¹11 . Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004; 14(3): 246-51. ^{, 19}19 . Macinko J, Guanais FC, Souza MFM. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60(1): 13-9.

20 . Magan P, Otero A, Alberquilla A, Ribera JM. Geographic variations in avoidable hospitalizations in the elderly, in a health system with universal coverage. BMC Health Serv Res 2008; 8: 42. ^{- 21}21 . Ceccon RF, Borges DO, Paes LG, Klafke JZ, Viecili PRN. Mortalidade por doenças circulatórias e evolução da saúde da família no brasil: um estudo ecológico. Ciênc Saúde Coletiva 2013; 18(5): 1411-6. ^{, 23}23 . Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991-1998: assessing trends and inequities of quality in primary care. J Epidemiol Community Health 2003; 57(1): 17-22.

24 . Sanchez M, Vellanky S, Herring J, Liang J, Jia H. Variations in Canadian rates of hospitalization for ambulatory care sensitive conditions. Healthc Q 2008; 11(4): 20-2.

25 . Pirani M, Schifano P, Agabiti N, Davoli M, Caranci N, Perucci C. Ospedalizzazione potenzialmente evitabile nella città di Bologna, 1997-2000: andamento temporale e differenze per livello di reddito. Epidemiol Prev 2006; 30(3): 169-77. ^{- 26}26 . Caminal J, Mundet X, Ponsà JA, Sánchez E, Casanova C. Las hospitalizaciones por ambulatory care sensitive conditions: selección del listado de códigos de diagnóstico válidos para Espana. Gac Sanit 2001; 15(2): 128-41.. On the other hand, when health care is performed by services who do not work with the FHS, there is significant increase in hospitalization rates for ACSC⁴4 . Fernandes LCL, Bertoldi AD, Barros AJD. Utilização dos serviços de saúde pela população coberta pela Estratégia de Saúde da Família. Rev Saúde Pública 2009; 43(4): 595-603.. The longitudinal aspect of care provided by FHS professionals and the connection between users and workers contribute with the increasing resoluteness and with the reduction of hospitalizations¹³13 . Nedel FB, Facchini LA, Marín-Mateo M, Vieira LAS, Thumé E. Desempenho do ESF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da atenção básica à saúde. Ciênc Saúde Coletiva 2006; 11: 669-81. ^{, 27}27 . Roos LL, Walld R, Uhanova J, Bond R. Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a Canadian setting. Health Services Research 2005; 40(4): 1167-85..

Lower hospitalization rates for ACSC are related to the potential of FHS to work effectively on the main causes of avoidable hospitalizations. However, the reducing number of hospitalizations can also be a result of the insufficient number of beds and barriers in hospital access²⁷27 . Roos LL, Walld R, Uhanova J, Bond R. Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a Canadian setting. Health Services Research 2005; 40(4): 1167-85..

The low FHS population coverage leads to the reduced access to health services, the maintenance of the assistance perspective addressed to the disease and to the weaker emphasis on activities of promotion and prevention. When there is reduced number of health professionals in primary care, hospitalizations for ACSC increase. Therefore, hospitalization represents the outcome of itineraries in which the health problem was not resolved at primary care.

Other factors, like accessibility to the hospital, criteria adopted for hospitalization and health insurance coverage should also be considered for the analysis of hospitalizations for ACSC²⁸28 . Bermúdez-Tamayo C, Márquez-Calderón S, Rodríguez AMM, Perea-Milla LE, Ortiz EJ. Características organizativas de la atención primaria y hospitalización por los principales ambulatory care sensitive conditions. Aten Primaria 2004; 33(6): 305-11.

29 . Falik M, Needleman J, Herbert R, Wells B, Politzer R, Benedict MB. Comparative effectiveness of health centers as regular source of care: application of sentinel ACSC events as performance measures. J Ambul Care Manage 2006; 29(1): 24-35.

30 . Caminal HJ, Morales EM, Sánchez RE, Cubells LMJ, Bustins PM. Hospitalizaciones prevenibles mediante una atención primaria oportuna y efectiva. Aten Primaria 2003; 31(1): 6-17. ^{- 31}31 . Gusmano MK, Rodwin VG, Weisz D. A new way to compare health systems: avoidable hospital conditions in Manhattan and Paris. Health Affairs (Millwood) 2006; 25(2): 510-20.. Besides, it is known that elderly people³²32 . Valenzuela LMI, Gastón MJL, Melquizo JM, Valenzuela LMM, Bueno CA. To identify primary care interventions that reduce hospitalization of people over 65 due to ambulatory care sensitive conditions. Aten Primaria 2007; 39(10): 525-32., with low income and schooling³³33 . Ansari Z, Laditka JN, Laditka SB. Access to health care and hospitalization for ambulatory care sensitive conditions. Med Car Res Rev 2006; 63(6): 719-41., are hospitalized more often, so this indicator increases in States in which the proportion of elder is higher.

The differences found between the Federation Units in avoidable hospitalization rates, concerning both the reduction and the rise, can also be related to structure factors, such as socioeconomic and cultural inequities. The low resoluteness of actions that are not so complex in the health system, together with the difficulties in the reference system, can also interfere in avoidable hospitalizations⁴4 . Fernandes LCL, Bertoldi AD, Barros AJD. Utilização dos serviços de saúde pela população coberta pela Estratégia de Saúde da Família. Rev Saúde Pública 2009; 43(4): 595-603..

Even though this study indicated strong association between the FHS coverage and hospitalizations for ACSC, some limits should be considered, including incorrect diagnoses corresponding to hospitalizations, which result in distorted information of the real profile of hospitalizations for ACSC¹⁷17 . Iezzoni LI. Assessing quality using administrative data. Ann Intern Med 1997; 127(82): 666-74..

The findings concerning hospitalizations cannot be exclusively understood as a result of FHS actions, since this study did not control confounding factors by analyzing other explanatory variables¹⁵15 . Morgenstern H. Ecologic studies. In: Rothman KJ, Greenland S. Modern epidemiology. Philadelphia: Lippincott Williams & Wilkins; 1998. p. 459-80.. Also, this investigation did not consider the different financing policies of SUS hospitalizations, which concern the financing cap obtained by the number of hospitalizations or by decentralization policies and control of AIHs.

Anyway, the assessment of FHS impact on the health conditions of the population is important to readapt the primary care model¹¹11 . Caminal J, Starfield B, Sanchez E, Casanova C, Morales M. The role of primary care in preventing ambulatory care sensitive conditions. Eur J Public Health 2004; 14(3): 246-51. ^{, 19}19 . Macinko J, Guanais FC, Souza MFM. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health 2006; 60(1): 13-9.

20 . Magan P, Otero A, Alberquilla A, Ribera JM. Geographic variations in avoidable hospitalizations in the elderly, in a health system with universal coverage. BMC Health Serv Res 2008; 8: 42. ^{- 21}21 . Ceccon RF, Borges DO, Paes LG, Klafke JZ, Viecili PRN. Mortalidade por doenças circulatórias e evolução da saúde da família no brasil: um estudo ecológico. Ciênc Saúde Coletiva 2013; 18(5): 1411-6., besides providing subsidies to quality health services⁶6 . Gil CRR. Formação de recursos humanos em saúde da família: paradoxos e perspectivas. Cad. Saúde Pública 2005; 21(2): 490-8..

CONCLUSION

In this study, we analyzed hospitalization rates for ACSC, an indicator that evaluates the quality of care and the effectiveness of care provided by Primary Care. This indicator assumes that the occurrence of hospitalizations due to a sensitive cause to primary care is a result of the lack of opportune and effective attention to the problem, thus leading to the aggravation of the clinical condition and, consequently, to hospitalization.

Even though there may be other determinants, the amplification of Primary Care and FHS coverage in Brazil, in the past few years, contributed with the reduced number of hospitalizations for ACSC. We observed an association between these two events, even knowing that the magnitude of social inequities between States contributes with increasing disease load and interferes in the effectiveness of public health policies in all levels of care.

Many studies have pointed out to improvements in the quality of Primary Care in the country in the past years. Even so, the indicators hospitalizations for ACSC is still little used, and other investigations are necessary, based on complementary sources and different methodological approaches. It is suggested to conduct further studies about the theme, including the management of AIHs and their impact on the number of hospitalizations. We believe that these findings can lead to the analysis of some critical points of primary care in Brazil, assisting in the evaluation of health actions, especially of FHS.

REFERENCES

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