Assessment of primary health care from the perspective of patients hospitalized for ambulatory care sensitive conditions

Effective primary care attenuates the association between frailty and hospital admission in old age: the ELSI-Brazil

BACKGROUND

Frailty is a multidimensional syndrome leading to a higher hospitalization. However, few studies explicitly analyze whether measures of effective primary care modify the relationship between frailty and hospital admission.

METHODS

This cross-sectional study included data from the second wave of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a representative community-based study with older adults aged 50 years and over, conducted in 2019-2021. Self-reported hospital admission in the past 12 months was the outcome. Frailty included the 5 phenotypic criteria: weight loss, exhaustion, low physical activity, weakness, and slowness. The effective primary care index included 12 attributes indicators, continuously. Statistical analyzes comprised logistic regression.

RESULTS

Among the 7,436 study participants, frailty (odds ratio [OR] 2.17; 95% confidence intervals [95% CI] 1.31-3.62) and effective primary care index (OR 1.10; 95% CI 1.03-1.16) were positively associated with higher hospitalization. Interaction revealed that while effective primary care was positively associated with hospitalization, this association was different among frail older adults (OR 0.80; 95% CI 0.65-0.99). After stratification by frailty status, positive association with hospitalization remained only among prefrail and nonfrail individuals. The predicted probability of hospitalization tended to decrease along with higher primary care index values among frail older adults and became similar to prefrail/nonfrail at the highest end of the scale.

CONCLUSIONS

Effective primary care decreases the likelihood of hospital admission among frail older adults. Interventions for delaying frailty should be initiated in primary care along with policies to strengthen primary care's organizational and provider/team-level attributes.

Patients' Perspectives on Determinants Avoidable Hospitalizations: Development and Validation of a Questionnaire

Ambulatory care sensitive conditions (ACSC) can be avoided through effective care in the ambulatory setting. Patients are the most qualified individuals to express the social and individual contexts of their own experience. Thus, understanding why potentially preventable hospitalizations occur is important to develop patient-centred policies or interventions that may reduce them. This study aims to develop and validate a questionnaire to capture the patients’ perspective on the causes of the hospitalizations for ACSC. The development of a new questionnaire involved four phases: a literature review, face validity, pre-test, and validation. We conducted a three-step face validity verification to confirm the relevance of the identified determinants and to collect determinants not previously identified by interviewing healthcare providers, representatives of patients’ associations, and patients. Determinants were identified through the literature review predominantly in the “Healthcare Access”, “Disease self-management”, and “Social Support” domains. The validated resulting questionnaire comprises 25 questions, distributed by two dimensions (individual/contextual) covering seven domains and 20 determinants of ACSC hospitalization. Currently, there are no validated instruments as comprehensive and easy to use as the one described in this paper. This questionnaire should provide a base for further language/context validations.

Avoidable hospitalizations in Brazil and Portugal: Identifying and comparing critical areas through spatial analysis

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions have been used to assess the performance of primary health care. Few studies have compared geographic variation in rates of avoidable hospitalizations and characteristics of high-risk areas within and between countries. The aim of this study was to identify and compare critical areas of avoidable hospitalizations in Brazil and Portugal, because these countries have reformed their primary health care systems in recent years and have similar organizational characteristics.

METHODS

An ecological study on hospitalizations for ambulatory care sensitive conditions produced in Brazil and Portugal in 2015 was used. Geographic variation of rates were analyzed and compared at the municipal level. A spatial scan statistic was employed to identify clusters with higher risk of hospitalizations for acute and chronic conditions in each country separately. Socioeconomic and primary health care characteristics of critical areas were compared to non-critical areas.

RESULTS

There were high variations in rates of avoidable hospitalizations within and between Brazil and Portugal, with higher variations found in Brazil. A more evident pattern of rates was found in Portugal. Rates and cluster distribution of acute and chronic conditions had significant agreement for both countries. The differences in primary health care and socioeconomic characteristics between areas identified as high risk clusters and non-clusters varied between category of conditions and between countries.

CONCLUSION

Brazil and Portugal presented expressive regional differences with respect to rates of avoidable hospitalizations, indicating that there is room to improve by reducing such events in both countries. Different areas presented distinct interactions between primary health care, socioeconomic characteristics, and avoidable hospitalizations. Results indicate that the primary health care reforms, with similar organizational characteristics in different contexts, did not produce similar results either between or within countries. Possible actions to reduce these events should be defined at a local level.

Reform movements in the Federal District Health Care System:conversion of the Primary Health Care assistance model

CONCLUSION

The Unified Health System has undergone constant evolution and expansion since the publication of Brazil's 1988 Federal Constitution. The Federal District has provided contributions to the field of Primary Health Care Policy, especially between 2016 and 2018, by defining the Family Health Strategy as the definitive way of organizing Primary Health Care (PHC) services and by establishing a set of actions aimed at conversion of existing PHC services to this model. This article describes and analyzes the key processes of this change. The method used was analysis of ordinances, resolutions, reports and other documents, as well as assessment of data from official databases. We emphasize the development of a normative structure that includes the teams' implementation, the professionals' work processes, changes in medical specialties and reorganization of the health professionals who already worked in PHC. with an effect of increasing the population's Family Health Strategy coverage (in a population of approximately 3 million inhabitants) from 28% to 69% during a two-year period, the experience demonstrates the feasibility of incremental changes in health policies such as defining priorities, better management of the workforce, training and decentralized planning to increase access to health services.

Primary health care as assessed by health professionals: comparison of the traditional model versus the Family Health Strategy

ABSTRACT: Introduction: The Family Health Strategy (FHS) should be first-contact care in the Brazilian Health System. However, Primary Health Care (PHC) still encompasses two models: the FHS and the traditional health care facilities. The expansion of the FHS has been slow and heterogeneous in many cities, rendering a comparative evaluation of key quality-related elements of PHC models crucial. Objective: To compare the performance of PHC models as perceived by health professionals. Methods: A cross-sectional study involving managers and health professionals from PHC of a medium-size city in South-eastern Brazil. Data were collected by applying the Primary Care Assessment Tool. The performance was estimated through primary health care indexes (general and partial PHCI by attributes). Univariate polytomous logistic regression was performed to compare care model performances according to their attributes. Strength of association was estimated by odds ratio with 95% confidence interval. Results: Three managers and 81 health professionals participated in the study. The FHS had a better index rating than the traditional care model for general PHCI and for the attributes longitudinality, comprehensiveness, family focus and professional level. Conclusion: Although the FHS attained higher scores compared to the traditional model, it has not yet achieved the performance expected. This scenario points to the need for increased FHS cover and quality improvements at the existing units.