Abstract

OBJECTIVE:

to analyze time trends and describe the causes of hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) in children under five years old in Ceará, Brazil, 2000-2012.

METHODS:

this is an ecological time series study using data from the National Hospital Information System; trends were analyzed using Prais-Winsten regression.

RESULTS:

from 2000 and 2016 ACSC hospitalization rates fell from 32.5 to 11.2/1,000 inhabitants under five years old (annual variation of -16.8%; 95%CI -20.6;-10.9); the cause groups with the largest reductions were nutritional deficiencies (-94.7%), infectious gastroenteritis (-52.6%), asthma (-59.0%) and bacterial pneumonias (-8.9%); the greatest reduction was found in the post-neonatal component (-22.4%); the hospitalization rate for prenatal and childbirth-related diseases increased 15 times among children under one year old.

CONCLUSION:

despite reduced ACSC hospitalization rates, preventable conditions were found that may reflect gaps in Primary Health Care.

Key words:
Primary Health Care; Child Health; Hospitalization; Time Series Studies; Ecological Studies

Introduction

Health indicators represent essential assessment and monitoring tools of health services. One of these indicators, the Hospitalizations for Ambulatory Care Sensitive Conditions (ASCS), correspond to health problems which are closely related to primary health care; good quality primary health care services can reduce the risk of hospitalizations due to these preventable causes.¹1. 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 jun;25(6):1337-49.

Hospitalizations for ASCS, also known as preventable hospitalizations, represent an important tool to verify, indirectly, the effectiveness and effectiveness of the assistance given by the first level of health care.²2. 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 de literatura. Epidemiol Serv Saude. 2010 jan-mar;19(1):61-75. In this sense, monitoring these hospitalizations is essential for supporting decisions which aim to reduce the high number of preventable hospitalizations.³3. 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 mar;28(3):515-26.

These unnecessary hospitalizations possibly reflect gaps in the health care system related to provide qualified access to Primary Health Care, since the group of diseases responsible for such hospitalizations should be early detected. Actions timely and effectively offered in the first care level of the health system can reduce diseases' severity, avoiding complications and the need for hospitalization.⁴4. Macinko J, Dourado I, Guanais FC. Doenças crônicas, atenção primária e desempenho dos sistemas de saúde: diagnósticos, instrumentos e intervenções. Nova York: Banco Interamericano de Desenvolvimento; 2011. (Textos para debate # IDB-DP-189)

The first studies on hospitalizations for ASCS were developed in the United States of America and pointed to the elimination of access barriers to health services as a decreasing factor of preventable hospitalizations.⁵5. Billings J, Teicholz N. Uninsured patients in District of Columbia hospitals. Health Aff (Millwood).1990;9(4):158-65. From those studies, many other studies have been developed under this theme, in various countries and contexts, participants and diverse methodologies. In spite of the plurality of methodologies and research scenarios, there seems to be an agreement in international literature in which preventable hospitalizations are markers of Primary Health Care effectiveness, associated to difficulties in the access to quality services, especially among vulnerable populations.⁶6. Fiorentini G, Iezzi E, Lippi BM, Ugolini C. Incentives in primary care and their impact on potentially avoidable hospital admissions. Eur J Health Econ. 2011 Aug;12(4):297-309.

7. 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 Sept-Oct;21(5):1159-64.

8. Butler DC, Thurecht L, Brown L, Konings P. Social exclusion, deprivation and child health: a spatial analysis of ambulatory care sensitive conditions in children aged 0-4 years in Victoria, Australia. Soc Sci Med. 2013 Oct;94:9-16.^-99. Rubinstein A, López A, Caporale J, Valanzasca P, Irazola V, Rubinstein F. Avoidable hospitalizations for ambulatory care sensitive conditions as an indicator of primary health care effectiveness in Argentina. J Ambul Care Manage. 2014 Jan-Mar;37(1):69-81.

In 2008, the Brazilian Health Ministry launched the Brazilian list of hospitalizations for ASCS.¹⁰10. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria n. 221, de 17 de abril de 2008. Publica, na forma do anexo desta portaria, a lista brasileira de internações por condições sensíveis à atenção primária. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2008 abr 18; Seção 1:70. This list, which is a result of a validation work performed by many Public Health specialists of the country, covers 19 groups of diagnoses considered sensitive to Primary Health Care and classified according to the International Statistical Classification of Diseases and Related Health Problems - 10^th Revision (ICD-10).¹1. 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 jun;25(6):1337-49.

With regard to hospitalizations for ASCS among children under five years old and respective age subgroups (0 to 27 days; 28 days to 11 months; 1-4 years), which is a group of the population that frequently uses the primary health care services offered by the Family Health Strategy (FHS) in Brazil, many studies have been developed aiming to understand the magnitude, context and characteristics of those hospitalizations.³3. 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 mar;28(3):515-26.^,1111. Moura BLA, Cunha RC, Aquino R, Medina MG, Mota ELA, Macinko J, et al. 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 nov;10 supl 1:S83-91.^,1212. Caldeira AP, Fernandes VBL, Fonseca WP, Faria AA. Hospitalizações pediátricas por condições sensíveis à atenção primária em Montes Claros, Minas Gerais, Brasil. Rev Bras Saude Mater Infant. 2011 jan-mar;11(1):61-71. Those studies show the high prevalence of acute conditions in pediatric hospitalizations, such as diseases of the respiratory tract and gastroenteritis,¹¹11. Moura BLA, Cunha RC, Aquino R, Medina MG, Mota ELA, Macinko J, et al. 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 nov;10 supl 1:S83-91.^,1313. Santos ILF, Gaíva MAM, Abud SM, Ferreira SMB. Hospitalização de crianças por condições sensíveis à atenção primária. Cogitare Enferm. 2015 jan-mar;20(1):171-9.^,1414. Oliveira BRG, Vieira CS, Collet N, Lima RAG. Causas de hospitalização no SUS de crianças de zero a quatro anos no Brasil. Rev Bras Epidemiol. 2010 jun;13(2):268-77. and that the reduction of hospitalizations for ASCS is closely related to the improvement in the offer and effectiveness of primary actions in health, mostly when developed by FHS teams.¹⁵15. Aquino R, Oliveira NF, Barreto ML. Impact of the family health program on infant mortality in Brazilian municipalities. Am J Public Health. 2009 Jan;99(1):87-93.

16. Fernandes VBL, Caldeira AP, Faria AA, Rodrigues Neto JF. Internações sensíveis na atenção primária como indicador de avaliação da Estratégia Saúde da Família. Rev Saude Publica. 2009;43(6):928-36.

17. 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 Apr;31(4):744-54.^-1818. Ceccon RF, Meneghel SN, Viecili PRN. Internações por condições sensíveis à atenção primária e ampliação da Saúde da Família no Brasil: um estudo ecológico. Rev Bras Epidemiol. 2014 out-dez;17(4):968-77.

Despite the increasing number of studies dedicated to hospitalizations for ASCS in children, researches on the specific causes of hospitalizations in neonatal and post-neonatal period, among children under one year, those from one to four years and under five years are still scarce. This study aimed to analyze time trends and to describe the causes of Hospitalizations for Ambulatory Care Sensitive Conditions - ASCS - in children under five years old in Ceará, Brazil, from 2000 to 2012.

Methods

This is an ecological time series study on ASCS hospitalization rates in the state of Ceará, Brazil, in the period from 2000 to 2012.

The information sources to the research were the National Hospital Information System (SIH/SUS) and the Information System on Live Births (Sinasc), besides demographic data provided by the Brazilian Institute of Geography and Statistics (IBGE). All of these data are secondary, of public domain, and were accessed at SUS IT Department website (www.datasus.gov.br). The software Tab for Windows - TabWin version 3.6b - was used for data extraction.

All hospitalizations of children under five years old that occurred between January 2000 and December 2012 at SUS or its associated network of hospitals were included, for all the municipalities of the state of Ceará.

ASCS hospitalization rates, according to the most frequent hospitalization causes due to sensitive conditions, were calculated considering the disease groups described in the Brazilian list of hospitalizations for ASCS.¹⁰10. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria n. 221, de 17 de abril de 2008. Publica, na forma do anexo desta portaria, a lista brasileira de internações por condições sensíveis à atenção primária. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2008 abr 18; Seção 1:70. The hospitalization rates of the seven main ASCS causes were calculated, for the following age groups: from 0 to 27 days (neonatal); from 28 days to 11 months (post-neonatal); under 1 year; from 1 to 4 years; and under 5 years.

In the groups of children from 0 to 27 days, 28 days to 11 months and under 1 year, rates were calculated by dividing the number of hospitalizations for ASCS, in each age group, by the total of live births in the given year (Sinasc), and then multiplied by 1,000. ASCS hospitalization rates for children from 1 to 4 years were calculated by diving the total of hospitalizations in this group by the number of children in the same age group in each year (IBGE), multiplying the result by 1,000. For children under five, the rates corresponded to the ratio between the total hospitalizations for this age and the number of children in this age group, for each year, multiplied by 1,000.

After calculating these indicators, for the descriptions of hospitalizations for ASCS, we chose to present the municipalities’ medians in the tables, to avoid data dispersion that could compromise the average. The rates percentage variation in the time series was calculated by comparing the values of the last to those of the first year. To calculate this percentage variation, the value of the rate of the last year was deducted from the value of the rate of the first year, and this difference was divided by the rate value for the first year.

Besides describing the variation of ASCS hospitalization rates, according to the main causes by age group, we estimated the time trends of hospitalization rates of total ASCS. For this, we used preventable hospitalization rates for each municipality of Ceará, per year. It should be highlighted that the total ASCS for each age group represents all 19 groups of causes of the Brazilian list, not only the most frequent causes. Prais-Winsten general linear regression was used for time trends analysis, to estimate beta 1 (b1. 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 jun;25(6):1337-49.) coefficients; and then, the annual percentage change was estimated and its respective 95% confidence intervals (95%CI), for each age group analyzed. The analyses were performed using Stata software version 12.

Despite using free access secondary data, available in public sources, without personal identification of the hospitalized children, the study's project was submitted and approved by the Ethics Research Committee of Ceará State University, under the Report No. 923.491, in December 11, 2014.

Results

In Ceará, 388,973 hospitalizations for ASCS were registered in children under five years old, from 2000 to 2012, with reduction from 35,989 to 17,358 between the first and the last years of the period. ASCS hospitalization rate in children under five years ranged from 32.5/1,000 inhabitants in 2000 to 11.2/1,000 inhabitants in 2012, which corresponds to a 65.5% reduction in 13 years.

With regard to hospitalization rates in children from 0 to 27 days of life, a reduction in hospitalizations due to bacterial pneumonias (-58.5%), gastroenteritis (-51.1%) and asthma (-36.7%) was observed; however, there was an increase for other causes. A 21-time increase in hospitalization rates for prenatal and childbirth-related diseases was observed, and those became the main hospitalization causes in this age group in 2012. Even though there has been a considerable decline in hospitalizations due to gastroenteritis, this cause represented the second higher hospitalization rate in the last year of the studied period. The time trends analysis revealed annual percentage increase of 17.5% (95%CI: 7.2;28.8) in ASCS hospitalization rate for the neonatal group (Table 1).

In children from 28 days to 11 months, there has been a reduction in hospitalization rates for nutritional deficiencies (92.3%), infectious gastroenteritis (78%), asthma (68.2%) and bacterial pneumonias (27.6%). On the other hand, there has been an increase in hospitalization rates for kidney infections (170.0%) and pulmonary diseases (94.0%). Although the considerable reduction presented, infectious gastroenteritis had remained as the main specific cause of preventable hospitalization for that age group, between 2000 and 2012. Time trends analysis has showed an annual percentage reduction of 22.4% (95%CI: -22.2; -16.8) in ASCS hospitalization rate for the post-neonatal group (Table 2).

The analysis of specific hospitalization rates per group of sensitive causes in children under 5 years old revealed a reduction in hospitalizations due to nutritional deficiencies (90.0%), infectious gastroenteritis (77.5%), asthma (67.6%) and bacterial pneumonias (30%), and an increase in hospitalizations due to other causes, and a 15-time increase in hospitalization rates due to prenatal and childbirth-related diseases. Concerning the increase of hospitalizations due to kidney infections, this cause remains as one with the lowest magnitude in the group of hospitalizations for ASCS. The time trends analysis has showed an annual percentage reduction of 20.6% (95%CI -25.9;-14.9) in ASCS hospitalization rate for children under one year (Table 3).

In the group of children aged from 1 to 4 years, the most frequent preventable hospitalization causes also presented infectious gastroenteritis, asthma and bacterial pneumonias. The decrease in hospitalization rates due to nutritional deficiencies (97.8%), asthma (55.1%) and gastroenteritis (27.1%) should be highlighted; despite the fact that the latter remains as the most frequent cause for all the studied years. Unlike what has happened in other age groups, in this preschooler range, the hospitalization rates due to bacterial diseases basically remained stable. The time trends analysis has shown an annual percentage decrease of 12.9% (95%CI -18.7;-6.7) in the ASCS hospitalization rate for children aged from 1 to 4 years (Table 4).

The analysis of hospitalizations for ASCS in children under five years old has shown that infectious gastroenteritis, asthma and bacterial pneumonias remain as the main hospitalization reasons in the group of preventable causes, a profile similar to the other analyses per age group. In this broader age group, the 94.7% reduction in hospitalizations due to nutritional deficiencies stand out, making it no longer the fourth, but the last among the seven main causes of hospitalizations for ASCS; besides reductions above 50% in hospitalizations due to gastroenteritis and asthma. The time trends analysis has revealed an annual percentage reduction of 16.8% (95%CI -20.6;-10.9) in ASCS hospitalizations rate for children under five years (Table 5).

Discussion

In Ceará, from 2000 to 2012, there has been a significant decrease in the occurrence of hospitalizations for ASCS among children under five years old and in their age subgroups. The reductions in the hospitalization rates due to nutritional deficiencies, infectious gastroenteritis, asthma and bacterial pneumonias, in the various age groups have stood out. This reduction in the group of preventable causes, and hospitalizations due to prenatal and childbirth-related diseases presented a high magnitude increase in the group of children up to 27 days of life. We should also highlight the reduction trend of hospitalizations for ASCS in almost all age groups, except for neonatal group, in which we observed a discrete increasing trend over the historic series.

This study’s results support evidences of other studies conducted in Brazil which have also presented ASCS hospitalization rate's reduction in children.³3. 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 mar;28(3):515-26.^,1010. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria n. 221, de 17 de abril de 2008. Publica, na forma do anexo desta portaria, a lista brasileira de internações por condições sensíveis à atenção primária. Diário Oficial da República Federativa do Brasil, Brasília (DF), 2008 abr 18; Seção 1:70.^,1313. Santos ILF, Gaíva MAM, Abud SM, Ferreira SMB. Hospitalização de crianças por condições sensíveis à atenção primária. Cogitare Enferm. 2015 jan-mar;20(1):171-9.^,1919. Boing AF, Vicenzi RB, Magajewski F, Boing AC, Moretti-Pires RO, Peres KG, et al. Reduction of ambulatory care sensitive conditions in Brazil between 1998 and 2009. Rev Saude Publica. 2012 Feb;46(2):359-66. The differences in the characteristics of those hospitalizations result from various factors, such as socioeconomic characteristics of the population, epidemiological conditions, health services’ characteristics and other peculiarities, inherent to each Brazilian region, state or municipality.¹¹11. Moura BLA, Cunha RC, Aquino R, Medina MG, Mota ELA, Macinko J, et al. 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 nov;10 supl 1:S83-91.

The highest ASCS hospitalization rates were found in the group of children under one year old, and the post-neonatal group was the main responsible for those hospitalizations and also for the most expressive decreasing rates. A study conducted in a public hospital in the state of Paraná, which aimed to understand the causes of hospitalizations in children under five years old, has verified, similarly, a predominance of hospitalizations in children under one year old, showing that 42% of hospital admissions have occurred in this age group.²⁰20. Oliveira RR, Costa JR, Mathias TAF. Hospitalizações de menores de cinco anos por causas evitáveis. Rev Latino-Am Enfermagem. 2012 jan-fev;20(1):135-42.

The high occurrence of hospitalizations among children under one year old may be related to immunological immaturity, particular of this age group, putting them into a higher risk of diseases, whilst the most significant decreases in this age range may have suffered strong influence of the improvement in the offer and quality of health services, especially those related to primary health care, offered by FHS teams.

The analysis of the main diseases groups that lead to hospitalizations for ASCS has concluded, about almost every age group, that the most frequent causes of hospitalizations were infectious gastroenteritis and complications, asthma and bacterial pneumonias. The historic series description has evidenced that the higher reductions occurred in those ASCS hospitalization rates related to infectious gastroenteritis, notwithstanding those diseases have remained as the major determinant group of hospitalizations, whereas asthma and bacterial pneumonias took turns in second and third places.

A study on the most frequent hospitalization causes in children from zero to four years old in Brazil pointed to a prevalence of gastroenteritis in the North and Northeast regions, and to a smaller proportion in the Southeast region, considered the most developed region in the country. With regard to respiratory diseases, there have been hospitalizations prevalence in the South and Midwest regions, and a smaller rate in the North region, confirming climate influence over those diseases’ etiology and Brazilian regional inequalities, related both to health services accessibility and professionals and to the population's life conditions in each region.¹⁴14. Oliveira BRG, Vieira CS, Collet N, Lima RAG. Causas de hospitalização no SUS de crianças de zero a quatro anos no Brasil. Rev Bras Epidemiol. 2010 jun;13(2):268-77.

Concerning the most frequent causes of hospitalizations for ASCS, other studies conducted in states located in the Northeast region - Piauí and Pernambuco - presented findings similar to the present study. In Piauí, among children under five years old, there was a more evident reduction in hospitalizations due to infectious and parasitic diseases.³3. 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 mar;28(3):515-26. In Pernambuco, the main diagnostic groups were gastroenteritis and complications, asthma, bacterial pneumonias and pulmonary diseases, which, altogether, were responsible for 89.1% of hospitalizations.¹⁷17. 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 Apr;31(4):744-54.

In Brazil, the deepest reductions in infant mortality due to specific causes were observed for diarrhea and respiratory infections, which have decreased 92% and 82%, respectively.²¹21. Victora CG, Aquino EML, Leal MC, Monteiro CA, Barros FC, Szwarcwald CL. Saúde de mães e crianças no Brasil: progressos e desafios [Internet]. Amsterdã: Lancet; 2011 [citado 2016 ago 04]. Disponível em: Disponível em: http://dms.ufpel.edu.br/ares/bitstream/handle/123456789/279/15%20Sa%C3%BAde%20de%20m%C3%A3es%20e%20crian%C3%A7as%20no%20Brasil%20progressos%20e%20desafios.pdf?sequence=1
http://dms.ufpel.edu.br/ares/bitstream/h... Although these advances and the reduction in hospitalization rates and mortality due to infectious gastroenteritis, this evolution had not occurred homogenously among Brazilian macroregions, and gastroenteritis is still responsible for the increasing number of hospitalizations, especially among children under five years.¹¹11. Moura BLA, Cunha RC, Aquino R, Medina MG, Mota ELA, Macinko J, et al. 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 nov;10 supl 1:S83-91.

Some analyses conducted in municipal level pointed that the Family Health Program (FHP) brought positive results over infant mortality,¹⁵15. Aquino R, Oliveira NF, Barreto ML. Impact of the family health program on infant mortality in Brazilian municipalities. Am J Public Health. 2009 Jan;99(1):87-93.^,2222. Macinko J, Souza MFM, Guanais FC, Simoes CCS. Going to scale with community-based primary care: an analysis of the family health program and infant mortality in Brazil, 1999-2004. Soc Sci Med. 2007 Nov;65(10):2070-80. especially on the reduction of mortality due to diarrhea and pneumonias.²³23. 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 Jan;60(1):13-9.^,2424. Rasella D, Aquino R, Barreto ML. Reducing childhood mortality from diarrhea and lower respiratory tract infections in Brazil. Pediatrics. 2010 Sep;126(3):e534-40. In the Northeast region, children under five years old would be twice likely to be hospitalized due to diarrhea if they lived in areas not covered by FHP.²⁵25. 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. Cienc Saude Coletiva. 2006 jul-set;11(3):713-24.

In this study, an increase in pulmonary diseases for almost every age group investigated over the historic series has been observed. In the case of bacterial pneumonia, there was an initial panorama of increasing rates, mostly among children under one year, especially those aged from 28 days to 11 months. Pediatric beds offer over the years can explain, in part, the increase of these clinical hospital admissions due to bacterial pneumonias.

A research that aimed to evaluate the effect FHP over hospitalization rates due to pneumonia in children under five years who lived in Brazilian municipalities, between 1999 and 2009, found a positive association between the increase in FHP coverage and rates of pneumonia in age groups of children under one year and under two months. According to that research, that was a desirable effect, since clinical recommendation for the treatment of pneumonias in this age group occurs in hospital level, once they are considered severe cases. ²⁶26. Pamponet ML. O efeito do Programa Saúde da Família nas internações hospitalares por pneumonias em crianças menores de cinco anos no Brasil [dissertação]. Salvador: Universidade Federal da Bahia; 2012.

Other interesting aspect concerns to the exponential increase (2,100.00%) observed in hospitalizations due to prenatal and childbirth-related diseases in the age group from 0 to 27 days. Congenital syphilis is believed to be the main responsible for this increase of cases in Ceará - which is alarming, since this is considered a preventable disease, capable of causing serious damages in affected children.

In Ceará, congenital syphilis rate has increased considerably. From 2000 to 2009, it rose from 0.56 to 49.32 per 10 thousand live births. This increase in the number of cases can represent an improvement in notifications, as well as an evidence of the need to develop effective actions to control this disease. We can infer that the issue of congenital syphilis is closely related to the access and to low quality of prenatal care, which can be considered a marker of quality and maternal-infant assistance.²⁷27. Costa CC, Freitas LV, Sousa DM, Oliveira LL, Chagas ACMA, Lopes MVO, et al. Sífilis congênita no Ceará: análise epidemiológica de uma década. Rev Esc Enferm USP. 2013 fev;47(1):152-59.

This study has also shown an important reduction in the number of hospitalizations due to nutritional deficiencies, probably associated to the improvement of the families’ socioeconomic status, maternal schooling improvement, expansion of health services access and sanitation, besides a growth in the population's purchasing power over the years.²⁸28. Monteiro CA, Benício MHD, Konno SC, Silva ACF, Lima ALL, Conde WL. Causas do declínio da desnutrição infantil no Brasil, 1996-2007. Rev Saude Publica. 2009;43(1):35-43. In this sense, cash transfer programs, such as Bolsa Família Program, especially when directed to families in extreme poverty, can reflect in improvement in social status and, consequently, in the reduction of food insecurity and hunger among this population. ²⁹29. Segall-Corrêa AM, Marin-Leon L, Helito H, Pérez-Escamilla R, Santos LMP, Paes-Sousa R. Transferência de renda e segurança alimentar no Brasil: análise dos dados nacionais. Rev Nutr. 2008 jul-ago;21 supl:S39-51.

The decreasing trend of hospitalizations for ASCS in most of the age groups, especially in post-natal care group, keeps strict relation with potential impacts of public policies, such as Family Health Strategy and Bolsa Família Program.²⁸28. Monteiro CA, Benício MHD, Konno SC, Silva ACF, Lima ALL, Conde WL. Causas do declínio da desnutrição infantil no Brasil, 1996-2007. Rev Saude Publica. 2009;43(1):35-43.^-2929. Segall-Corrêa AM, Marin-Leon L, Helito H, Pérez-Escamilla R, Santos LMP, Paes-Sousa R. Transferência de renda e segurança alimentar no Brasil: análise dos dados nacionais. Rev Nutr. 2008 jul-ago;21 supl:S39-51. In turn, the observed trend of discreet increase of ASCS hospitalization rates in the neonatal group can reveal deficiencies in hospital care to newborns, especially in places with bad socioeconomic indicators.

This study presents as limitation the fact that the analysis has considered Ceará as a level of data aggregation, which may have hidden certain hospitalizations patterns, since some municipalities in Ceará are in extreme poverty conditions. These municipalities’ socioeconomic differences could reveal more serious scenarios, increasing or maintaining high levels of preventable hospitalizations, mostly where there is little infrastructure of primary public services, such as health services. In any case, we must highlight the importance of this research and its pioneering action in drawing an overview of hospitalizations due to preventable conditions in children under five years old, in a state of the Northeast region of Brazil.

All in all, this present study has revealed a reduction in hospitalizations for the main preventable condition groups, and a reduction in the magnitude of hospitalizations due to causes that once had been more common among children, as gastroenteritis, asthma and bacterial pneumonias. Significant decrease was also noticed in hospitalizations linked to nutritional deficiencies, a sign of improvement in life conditions and of decrease of extreme poverty.

However, high rates of hospitalizations for ASCS in Ceará still persist, indicating the need for effective and timely actions in health services, mainly in Primary Health Care. This study has revealed that the evaluation of health services offered to the population is extremely relevant, through the use of indicators able to establish a situational diagnosis and to serve as support for building and directing public policies whose objective would be to improve the services performance and quality.

Despite the advantages provided by the use of information systems in health on researches of Hospitalizations for Ambulatory Care Sensitive Conditions -ASCS -, it is imperative that new primary studies on this group of causes are developed with the purpose of better identifying the profile of hospitalized children and these hospitalizations determinants.

References

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