ABSTRACT:

The aim of this work is to describe the characteristics of hospital admissions owing to external causes in the public health system in Brazil in 2011. Data from the Hospital Information System of the Unified Health System (SIH/SUS) were analyzed to obtain the frequency, coefficient of hospitalization, and hospital morbidity indicators. Of the 973,015 admissions, falls (38.4%) predominated, followed by traffic accidents (15.8%). The estimated coefficient of hospitalization owing to external causes increased with the age, and it was higher in male patients and in the midwest region of the country. The average stay was higher in hospitalizations for traffic accidents (6.1 days) and assaults (6.0 days), while the hospital mortality rate reached higher values in hospitalizations for assaults (4.7%) and self-harms (4.0%). It is evident from the knowledge of the characteristics described the usefulness of hospital morbidity data for planning care actions and prevention of the external causes.

Keywords:
External causes; Accidents; Violence; Morbidity; Hospitalization; Descriptive epidemiology.

INTRODUCTION

External causes of morbidity and mortality include accidents and violence that cause some kind of injury, whether physical or mental, and that may or may not have death as a result¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Portaria n. 737, de 16 de maio de 2001. Aprova a Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Diário Oficial da União, Brasília, p. 3, 18 maio 2001. Seção 1.. Accidents (road traffic crashes, drowning, poisoning, falls, and burns) are unintentional and avoidable events, causing physical and emotional injuries, which may occur in domestic or social environments such as work, school, sports, and leisure¹1. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Portaria n. 737, de 16 de maio de 2001. Aprova a Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Diário Oficial da União, Brasília, p. 3, 18 maio 2001. Seção 1.. Violence, especially manifested by assaults, homicides, and suicides, is the use of physical force or power, as a threaten or real, against oneself, another person, or a group or community, which either results in or has any possibility of resulting in injury, death, psychological harm, developmental disabilities, or privation²2. World Health Organization. World report on violence and health. Geneva: World Health Organization; 2002..

These events are responsible for the death of five million people worldwide each year (~9% of global mortality), which presents a major challenge for the health sector, particularly in developing countries³3. World Health Organization. Injuries. Disponível em: http://www.who.int/topics/injuries/about/en/index.html (Acessado em 25 de julho de 2012).
http://www.who.int/topics/injuries/about... . Despite being one of the main causes of mortality, external causes are also responsible for the hospitalization of millions of people. Depending on the severity of the injuries, many of those who survive accidents and acts of violence continue to experience temporary or permanent sequelae⁴4. World Health Organization. Injuries and violence: the facts.; Geneva: World Health Organization 2010..

Despite the evidence of decline for some specific causes, homicide and traffic-related injuries account for nearly two-thirds of deaths owing to external causes in Brazil⁵5. Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MHP, Silva CMFP, Minayo MCS. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. The Lancet 2011; 377(9781): 1962-75.. In 2010, 143,256 Brazilians died because of accidents and violence (12.5% of all deaths in the country), of which the victims of homicide were 36.5%, and that of road traffic accidents (RTAs) were 29.9%. In the same year, 929,893 hospital admissions were authorized by injuries owing to external causes, accounting for 8.2% of hospitalizations financed by the Public Health System (SUS), at a cost of 940.5 million reais (8.7% of total admissions paid by SUS)⁷7. Mascarenhas MDM, Monteiro RA, Sá NNB, Gonzaga LAA, Neves ACM, Silva MMA, et al. Epidemiologia das causas externas no Brasil: morbidade por acidentes e violências. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: Uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde 2011. p. 203-24..

The profile of mortality owing to external causes of the Brazilian population has been extensively studied by researches addressing the epidemiological characteristics of the victims, the magnitude and the tendency of these diseases, and the data quality. Such analyzes use the data provided by the Mortality Information System (SIM), which provides, in the death certificate (DC), information that is systematically analyzed and widely disseminated to the intervention planning⁸8. Mello-Jorge MHP, Laurenti R, Gotlieb SLD. Análise da qualidade das estatísticas vitais brasileiras: a experiência de implantação do SIM e do SINASC. Ciênc Saúde Coletiva 2007; 12(3): 643-54..

However, there are still a few studies concerning the epidemiological pattern of hospitalizations resulting from external causes in Brazil. The epidemiological analysis of hospitalizations imposes itself as a major challenge to public health⁹9. Secretaria de Estado da Saúde de São Paulo. Grupo Técnico de Prevenção de Acidentes e Violências. Centro de Vigilância Epidemiológica "Prof. Alexandre Vranjac". Coordenadoria de Controle de Doenças. Internações hospitalares por causas externas no Estado de São Paulo em 2005. Rev Saúde Pública 2007; 41(1): 163-6. . Even still underutilized in epidemiological analysis and restricted to services funded by SUS, the data from the Hospital Information System of the Unified Health System (SIH/SUS) have been gradually employed in analyzes that go beyond the financial scope and examine the epidemiological behavior of hospital morbidity, including the external causes¹⁰10. Bittencourt AS, Camacho LAB, Leal MC. O Sistema de Informação Hospitalar e sua aplicação na saúde coletiva. Cad Saúde Pública 2006; 22(1): 19-30. ¹¹11. Tomimatsu MFAI, Andrade SM, Soares DA, Mathias TAF, Sapata MPM, Soares DFPP, et al. Qualidade da informação sobre causas externas no Sistema de Informações Hospitalares. Rev Saúde Pública 2009; 43(3): 413-20..

The SIH/SUS provides, from the hospital authorization form (AIH), demographic and clinical data, allowing the description of morbidity and the hospital mortality rate within the services by Unified Health System (SUS). It is estimated that the coverage of the system reaches approximately 70% of hospital admissions in the country, with variations between regions and states in Brazil, based on the percentage of the user population of private health plans¹²12. Pepe VE. Sistema de informações hospitalares do sistema único de saúde (SIH-SUS). In: Brasil. Ministério da Saúde. A experiência brasileira em sistemas de informação em saúde. Brasília: Ministério da Saúde 2009. p. 65-86..

While the nonfatal events are more common than the outcomes captured by the mortality records, it becomes essential to know the epidemiological aspects of hospitalizations owing to the external causes in order to support the planning of actions for preventing this practice. Hence, the aim of this article was to characterize hospital admissions owing to the external causes in SUS in Brazil, in 2011.

METHODS

This is a descriptive study whose population comprised all hospitalizations owing to external causes, conducted in the services of SUS in 2011. The data were obtained from HIS/SUS and were made available by the Secretary of Health Surveillance of the Ministry of Health through the electronic portal of the SUS Department of Information Technology (DATASUS).

The records selected had a secondary diagnosis, which corresponded to one of the codes of chapter XX of the International Statistical Classification of Diseases and Related Health Problems-Tenth Revision (ICD-10)¹³13. Organização Mundial da Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde - 10ª Revisão. São Paulo: Edusp; 1995., according to the following groupings:

Hospitalizations coded only with the nature of the injury (S00-S99, T00-T98 of Chapter XIX) were included in the group of "other external causes," to avoid underestimation of total hospitalizations owing to external causes.

Population data were collected on the basis of the Census 2000 and 2010 of the Brazilian Institute of Geography and Statistics (IBGE), available on the website of DATASUS, using the arithmetic interpolation calculation method to estimate the resident population in the year 2011. The descriptive variables were: gender (male and female); age (≤ 9, 10 - 19, 20 - 39, 40 - 59, and ≥ 60 years); race/skin color (white, black, black and brown, yellow, and indigenous); the geographic region of residence (north, northeast, southeast, south, and midwest).

The estimator of the coefficient of hospitalization per 100,000 inhabitants was calculated from the ratio between the number of hospitalizations owing to external causes paid by SUS, according to the place of residence (numerator) and the resident population (denominator). Thus, as the AIH uses the event (hospitalization) as a registration and reporting unit, the indicator built was an event number ratio (hospitalizations owing to external causes) divided by the resident population. Hence, this indicator does not express risk but allows to know the magnitude of the subject matter, here restricted to admissions that were paid by SUS. In addition, the indicators of average stay (total days of hospitalization/total number of admissions in the period) and hospital mortality (number of admissions that were discharged by death × 100/total number of admissions in the period) were calculated.

The TabWin 3.5 program was used to import the tabulations made in the DATASUS website, and Microsoft Excel 2010 was used to calculate the hospitalization coefficients, average stay, hospital mortality, and coefficients ratio.

The project was approved by the Research Ethics Committee of the Technology Sciences School of Piauí (NOVAFAPI) under the Opinion no. 137.435, from November 1, 2012.

RESULTS

A total of 973,015 hospitalizations owing to external causes in hospital services linked to SUS in Brazil in 2011 were recorded. With regard to sociodemographic characteristics, most patients were men (70.4%), aged 20-39 years (36.9%), whites (33.5%), and with a large participation of residents in the southeast (41.9%), which held 42.1% of the population in 2011. Most hospitalizations were because of accidental causes, represented by falls (38.4%) and RTAs (15.8%); however, the admissions for violence presented the lowest frequencies: aggression (5.1%) and self-harm (0.9%). The other external causes, including other accidents and events of undetermined intent, accounted for 39.9% of admissions. The distribution of different causes of hospitalization on the basis of variables such as sex, age, race/skin color, and geographic region of residence is shown in Table 1.

Regarding the distribution of hospitalizations owing to external causes according to specific causes and sex of patients, RTAs (17.6%) and assaults (5.9%) showed a higher proportion of admissions among men compared with women (11.5 and 3.2%, respectively). For women, the proportion of admissions for falls (44.1%) and self-harm (1.2%) exceeded the value observed among men. In absolute terms, the number of admissions was higher in male patients for all cases, eventually being 3.6 to 4.5 times the number of hospitalizations among women by RTAs and assaults, respectively. Hospitalizations for accidents involving male cyclists and motorcyclists were 4.4 and 5.3 times, respectively, the number observed in female subjects. Among hospitalizations for assaults, the frequency of events involving firearms between male victims was 10.6 times that observed among female patients (Table 2).

The estimated coefficient of hospitalization owing to external causes in Brazil in 2011 was 504.3 admissions per 100,000 inhabitants, showing a great variation of sex, age, and the type of cause. The highest rates were observed for hospital admissions owing to injuries from falls (193.5/100,000 inhabitants) and RTAs (79.6/100,000 inhabitants.), followed by admissions for assault (25.5/100,000 inhabitants) and self-harm (4.5/100,000 inhabitants.). In all causes and in all age groups, the rates were higher in male patients, except in hospitalizations owing to falls in the age group of 60 years or older. The hospital indicators of falls proved to increase with age, reaching a value of 433.8 admissions per 100,000 women aged 60 years or older. The highest coefficient of hospitalization for RTAs was observed among men aged 20 to 39 years (198.6/100,000 inhabitants) and women aged 20 to 39 years (40.1/100,000 inhabitants) and 60 years or older (41.0/100,000 inhabitants.). The highest rate of hospitalization for assault was observed among men aged 20 to 39 years (69.8/100,000 inhabitants) and women aged 20 to 39 years and 60 years or older. The hospital indicators for self-harm reached its maximum values among men aged 40 to 59 years (7.6/100,000 inhabitants) and women aged 20 to 39 years (4.9/100,000 inhabitants). The hospitalization rate owing to external causes was higher in the midwest region, except for hospitalizations from falls and self-harm, whose indicator was higher in the south and southeast, respectively (Table 3).

The average stay of hospitalizations owing to external causes was 5.2 days, ranging from 4.1 days for admissions for self-harm to 6.1 days for admissions because of RTAs. The duration of hospitalization was higher among male patients, except in hospitalizations from falls, and presented directly proportional evolution to the increasing age of patients, ranging from 3.4 days for children up to 9 years old to 6.8 days for patients aged 60 years or older. The hospital mortality was 2.5% for the total of hospitalizations owing to external causes, wherein the assaults (4.7%) and self-harm (4.0%) showed the highest values. The mortality rate was higher in male patients, except for admissions for falls, and directly proportional to the increasing age of patients (Table 4).

Falls of the same level and from a level to another resulted in hospitalizations with an average duration of 4.7 and 5.4 days, respectively, and lethality of 2.2%. Among the hospitalizations owing to RTAs, victims of trampling (pedestrians) and vehicle occupants demanded a greater length of hospital stay (average stay = 6.4 days), with the highest fatality rates (4.6% and 5.1%, respectively). Hospitalizations for injuries resulting from firearms lasted on an average 7.3 days, resulting in hospital mortality of 9.5%, the highest among the specific causes of hospitalization (Table 5).

DISCUSSION

The characteristics of hospital admissions owing to external causes in Brazil, in 2011, revealed the concentration of admissions of male patients and young adults. The estimated hospitalization rate was higher in male patients and proved to grow with the increasing age of victims. The preponderance of male patients in virtually all types of external causes of hospitalization draws attention to the gender relations involved in the society in which patients are inserted, resulting in an uneven distribution of admissions. These aspects, combined with the influence of behavioral differences and lifestyle for men and women, are proven by studies that also point to the predominance of men and young adults among hospital admissions owing to external causes in Brazil⁶6. Brasil; Ministério da Saúde. Saúde Brasil 2011: uma análise da situação de saúde e a vigilância da saúde da mulher. Brasília: Ministério da Saúde; 2012. ¹⁴14. Gawryszewski VP, Rodrigues EMS. The burden of injury in Brazil, 2003. Sao Paulo Med J 2006; 124(4): 208-13. ¹⁵15. Lignani LO, Villela LCM. Estudo descritivo sobre a morbidade hospitalar por causas externas em Belo Horizonte, Estado de Minas Gerais, Brasil, 2008-2010. Epidemiol Serv Saúde 2013; 22(2): 225-34. ¹⁶16. Souza ER, Lima MLC. Panorama da violência urbana no Brasil e suas capitais. Ciênc Saúde Coletiva 2006; 11(Suppl): 1211-22..

Falls occupied the first position among the hospitalizations owing to external causes, with a greater impact in the elderly, in which the estimated hospitalization rate among women exceeded that observed among men. Several studies have pointed out the elderly as the most vulnerable to the occurrence of falls¹⁷17. Perez M, Lourenço RA. Rede FIBRA-RJ: fragilidade e risco de hospitalização em idosos da cidade do Rio de Janeiro, Brasil. Cad Saúde Pública 2013; 29(7): 1381-91.. In Campinas (SP), a survey to assess the profile of elderly trauma victims treated at emergency services found that most patients were women, aged 70 to 74 years, with a higher incidence of falls of their own height¹⁸18. Lima RS, Campos MLP. Perfil do idoso vítima de trauma atendido em uma Unidade de Urgência e Emergência. Rev Esc Enferm USP 2011; 45(3): 659-64.. A research carried out in a neighborhood of Fortaleza (CE) found that the occurrence of falls among the elderly people was related to inadequate domestic environment, with emphasis on slippery surfaces, resulting in fractures and need of hospitalization in one-third of seniors, who reported a fall episode¹⁹19. Cavalcante ALP, Aguiar JB, Gurgel LA. Fatores associados a quedas em idosos residentes em um bairro de Fortaleza, Ceará. Rev Bras Geriatr Gerontol 2012; 15(1): 137-46..

RTAs are ranked as the second most frequent cause of hospitalizations owing to external incidental causes. The hospital indicators by road accidents among men were 3.8 times that seen among women. Traffic accidents are a global public health problem, especially in developing countries. In the last two decades, there has been an increase in deaths and hospitalizations owing to traffic accidents, especially when it comes to accidents involving motorcyclists, because such events disproportionately affect young men. The importance of motorcyclists to the current standard of mortality and morbidity from road accidents was demonstrated when Marín-León et al.²⁰20. Marín-León L, Belon AP, Barros MBA, Almeida SDM, Restitutti MC. Tendência dos acidentes de trânsito em Campinas, São Paulo, Brasil: importância crescente dos motociclistas. Cad Saúde Pública 2012; 28(1): 39-51. analyzed the tendency of occurrence of traffic accidents between 1995 and 2008 in the city of Campinas (SP). During this period, the motorcycle fleet grew 241%. Motorcyclists were responsible for the greatest run over coefficients (66.7 victims/1,000 accidents) and accidents resulting in death (4 deaths/1,000 accidents). Men revealed a much superior risk of facing death in traffic accidents compared with women. Another analysis conducted in the city of Maringá (PR) has estimated the average risk of hospitalization from traffic accidents in 19.4/100 victims (673 admissions), identifying pedestrians, cyclists, and motorcyclists as categories of victims with a higher risk of hospitalization.

The results of this analysis are consistent with the description of the profile of the traffic accidents patients treated at the emergency room at Goiânia (GO), among which predominated male, young (mean age 19.88 years; standard deviation of 2.7 years) victims and motorcycle occupants (67%)²²22. Caixeta CR, Minamisava R, Oliveira LMAC, Brasil VV. Morbidade por acidentes de transporte entre jovens de Goiânia, Goiás. Ciênc Saúde Coletiva 2009; 14(5): 1807-15.. Factors such as the recent economic changes in Latin American countries, the rapid increase in motorization coefficients, and the high availability of motorcycles as means of transport, associated with failure in policies of public transport and supervision of drivers, contribute to the growing number of accidents involving motorcycles²³23. Rodrigues EMS, Villaveces A, Sanhueza A, Escamilla-Cejudo JA. Trends in fatal motorcycle injuries in the Americas, 1998-2010. Int J Inj Contr Saf Promot 2013; DOI: 10.1080/17457300.2013.792289
https://doi.org/10.1080/17457300.2013.79... . Faced with this tragic scenario, it is necessary to implement effective measures to prevent such accidents and, consequently, contribute to the reduction of hospitalizations and deaths caused by them. Education measures are needed for the most vulnerable groups, encouraging the use of security and surveillance equipment that prioritize the periods of increased occurrence of accidents²²22. Caixeta CR, Minamisava R, Oliveira LMAC, Brasil VV. Morbidade por acidentes de transporte entre jovens de Goiânia, Goiás. Ciênc Saúde Coletiva 2009; 14(5): 1807-15. ²⁴24. Soares DFPP, Mathias TAF, Silva DW, Andrade SM. Motociclistas de entrega: algumas características dos acidentes de trânsito na região sul do Brasil. Rev Bras Epidemiol 2011; 14(3): 435-44..

Assaults are considered one of the most impactful causes of death among the external causes but had a limited participation in the panorama of hospitalizations. The low frequency of admissions for assaults in the number of deaths from the same cause would be explained by its high fatality at the scene and the underreporting in the hospital, either because of the patient's fear of revealing the assault or by a lack of interest/fear of health professionals that would collect and record such information²⁵25. Melione LPR, Mello-Jorge MHP. Gastos do Sistema Único de Saúde com internações por causas externas em São José dos Campos, São Paulo, Brasil. Cad Saúde Pública 2008; 24(8): 1814-24.. Although the impact of the attacks is a greater cause of mortality, hospital admissions from these causes must be analyzed carefully. Hospitalizations for assaults accounted for about 5% of cases owing to external causes in Brazil and showed the behavior similar to that seen in mortality from these causes: a predominance of young male victims¹⁴14. Gawryszewski VP, Rodrigues EMS. The burden of injury in Brazil, 2003. Sao Paulo Med J 2006; 124(4): 208-13.. However, women also appear in the list of victims of assault. In a study conducted at the Emergency Hospital of Porto Alegre (RS), the hospital's profile for abuse of women found that most cases were young people aged 18 to 29 years, with a predominance of assault by firearm²⁶26. Ilha MM, Leal SMC, Soares JSF. Mulheres internadas por agressão em um hospital de pronto socorro: (in)visibilidade da violência. Rev Gaúcha Enferm 2010; 31(2): 328-34..

Another important component of morbidity owing to external causes refers to self-harm, which, while presenting the lowest frequencies, should be considered before the persistence of this type of occurrence. Admission coefficients were higher among men in all ages, especially for the group of 20 to 59 years. Among women, the group of 20 to 39 years presented the highest rate of hospitalization for this type of injury. It should be noted that the difference in the coefficient of hospitalization for self-harm among elderly men was 2.4 times that observed among the elderly women. This result can be corroborated by the study of Minayo et al.²⁷27. Minayo MCS, Pinto LW, Assis SG, Cavalcante FG, Mangas RMN. Tendência da mortalidade por suicídio na população brasileira e idosa, 1980-2006. Rev Saúde Pública 2012; 46(2): 300-9., which showed a significant increase in mortality from suicide in Brazil, especially in the male population aged older than 60 years.

In a research conducted in a referral hospital with admissions of victims owing to external causes in the city of São José dos Campos (SP), Melione and Mello-Jorge²⁵25. Melione LPR, Mello-Jorge MHP. Gastos do Sistema Único de Saúde com internações por causas externas em São José dos Campos, São Paulo, Brasil. Cad Saúde Pública 2008; 24(8): 1814-24. found an average length of stay similar to that found in this study. However, the average time for hospitalizations because of falls in that city was twice the estimated on the basis of Brazil numbers, which can be explained by the quality of information from hospital records, which show a wide variation among the various establishments that provide data to the HIS/SUS, or the profile of hospitalized clientele in that city.

In describing the mortality rate, the severity of injuries owing to external causes that required hospitalization can be indirectly identified. Thus, the most serious injuries resulted from assaults, especially those involving a firearm, attempted suicides, and RTAs, especially when the victim was a vehicle occupant or pedestrian. This is because attempts to murder and suicide involve more lethal means, reducing the chance of victims survival²⁸28. Hennington EA, Meneghel SN, Barros FS, Silva LB, Grano MS, Siqueira TP, et al. Mortalidade por homicídios em Município da Região Sul do Brasil, 1996 a 2005. Rev Bras Epidemiol 2008; 11(3): 431-41. ²⁹29. Vidal CEL, Gontijo ECDM, Lima LA. Tentativas de suicídio: fatores prognósticos e estimativa do excesso de mortalidade. Cad Saúde Pública 2013; 29(1): 175-87..

In the case of RTAs, the factors that contribute to the high mortality rate among pedestrians are a great exposure of the body surface, lack of protective equipment, and vulnerability to the weight of the vehicle involved in the accident. For the occupants of vehicles, there is a lack of use of safety belt, exposure to throws, and movement during collision. The age difference of the victims according to types of road accidents should also be considered, because the mortality rate is higher among the elderly people. The speed of the vehicles involved is also a key element in determining the severity of injuries among pedestrians and occupants²⁰20. Marín-León L, Belon AP, Barros MBA, Almeida SDM, Restitutti MC. Tendência dos acidentes de trânsito em Campinas, São Paulo, Brasil: importância crescente dos motociclistas. Cad Saúde Pública 2012; 28(1): 39-51. ³⁰30. Gawryszewski VP, Coelho HMM, Scarpelini S, Zan R, Mello-Jorge MHP, Rodrigues EMS. Perfil dos atendimentos a acidentes de transporte terrestre por serviços de emergência em São Paulo, 2005. Rev Saúde Pública 2009; 43(2): 275-82.. It is noteworthy that male victims' mortality is evident when observing the higher mortality in admissions of male victims of assault and self-harm injuries. This aspect is proven in several studies that point to a higher incidence of fatal injuries among men, whether they are victims of homicides³¹31. Gawryszewski VP, Sanhueza A, Martinez-Piedra R, Escamilla JA, Souza MFM. Homicídios na região das Américas: magnitude, distribuição e tendências, 1999-2009. Ciênc Saúde Coletiva 2012; 17(12): 3171-82. or self-harm²⁷27. Minayo MCS, Pinto LW, Assis SG, Cavalcante FG, Mangas RMN. Tendência da mortalidade por suicídio na população brasileira e idosa, 1980-2006. Rev Saúde Pública 2012; 46(2): 300-9..

CONCLUSION

This study contributes to the knowledge of the characterization of hospital morbidity owing to external causes in public health services in Brazil, offering a more comprehensive understanding of these issues, as it complements widely known information on mortality ³²32. Dahlberg LL, Krug EG. Violência: um problema global de saúde pública. Ciênc Saúde Coletiva 2006; 11(Suppl): 1163-78..

However, it is necessary to clarify some limitations of the SIH/SUS that can influence the results presented in this study. Given the diversity of services distributed in the country, it is likely that the following situations occur:

Another point to be considered is the system's coverage, which is capable of recording approximately 70 to 90% of hospital admissions that occur in Brazil, varying according to the user portion of health plans in the different regions of the country³³33. Porto SM, Uga MAD, Moreira RS. Uma análise da utilização de serviços de saúde por sistema de financiamento: Brasil 1998-2008. Ciênc Saúde Coletiva 2011; 16(9): 3795-806. ³⁴34. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Coletiva 2011; 16(9): 3807-16.. Thus, it is suggested to conduct studies that show the hospitalization rate owing to external causes corrected by identifying the proportion of users of private health services and plans. Hence, it would be possible to estimate the hospitalization coefficient for all inhabitants.

Finally, despite the aforementioned limitations, the SIH/SUS holds a strong potential for epidemiological analysis, providing an essential tool for defining policies and programs, decision-making, and evaluation of results, as it identifies priority groups to develop specific strategies of prevention and assistance to external causes. However, it is necessary to invest in improvements in data quality, especially regarding the coding of the cause of admission. In addition, it should encourage analysis and dissemination of data from this system and boost the development of new studies and monitoring of hospital morbidity owing to external causes.

References

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