[The impact of primary healthcare and the reduction of primary health care-sensitive hospital admissions]

Time series of hospitalizations for primary care-sensitive conditions in children in the state of Roraima, Brazil, 2010 to 2023

OBJECTIVE

To analyze the trend of hospitalizations for primary care-sensitive conditions in children in the state of Roraima, Brazil.

METHODS

Ecological time series study with secondary data collected from the Hospital Information System, on hospitalizations for primary care-sensitive conditions in children between 2010 and 2023.

RESULTS

The highest hospitalization rates were in 2021 (265.9/10,000 inhabitants/year) and the under 1 age group had the highest rates. There was a reduction in ambulatory care-sensitive conditions in group 1, in the first and second segments (MPC=-1.50; 95%CI -3.79-0.32 p=0.016 and MPC=-1.91; 95%CI -3.44--0.81 and p=0.007), group 2, with a constant drop throughout the series of 0.57% per month (95%CI -0.70--0.43 and p<0.001) and in group 16 (MPC=-0.38; 95%CI -0.55--0.21 and p<0.001). Bacterial pneumonia was the main cause of hospitalization in all age groups. Group 4 showed a uniform increase in rates of 1.56% per month (95%CI 0.27-2.80 and p=0.018). There was a drop in rates in the first segment at all ages: <1 year: -2.90% and p=0.019; 1 to 4 years: -1.75% (p=0.011) and 5 to 9 years: -0.79% (p=0.053), followed by an increase and then a drop again. In the last segment, all the age groups showed an increase in rates.

CONCLUSIONS

The scenario in Roraima is worrisome and requires urgent interventions, as there is evidence of weaknesses in primary health care, probably aggravated by the migratory crisis. The strategies sought are still insufficient.

Effect of primary health care on the association between multimorbidity and emergency service utilization: National Health Survey, 2019

OBJECTIVE

To examine the effect of Primary Health Care (PHC) on the association between multimorbidity and emergency service utilization among adults in Brazil.

METHODS

This is a cross-sectional, nationwide household-based study using data from the 2019 National Health Survey. Poisson regression was used to assess emergency service utilization among individuals with multimorbidity. The interaction of variables such as Family Health coverage and orientation to PHC in these associations was also evaluated.

RESULTS

The prevalence of multimorbidity was 31.2% (95%CI 30.9-31.5), Family Health coverage was 71.8% (95%CI 71.4-72.0), and low orientation of services toward PHC was 70% (95%CI 69.1-70.9). Emergency service utilization had a prevalence of 2.0% (95%CI 1.9-2.0), being twice as high among individuals with multimorbidity (3.1; 95%CI 2.9-3.3) compared to those without this condition (1.4; 95%CI 1.3-1.5). However, individuals with multimorbidity and Family Health coverage had a 20% lower prevalence of emergency service utilization than those without Family Health coverage (PR 0.8; 95%CI 0.6-0.9). The association between emergency service utilization and multimorbidity was not modified by the evaluation of the service as highly oriented toward PHC (p=0.956).

CONCLUSION

The study showed that Family Health coverage exerted a positive effect on the association between multimorbidity and emergency service utilization.

Ten years of the Citizen's Electronic Health Record e-SUS Primary Healthcare: in search of an electronic Unified Health System

OBJECTIVE

Contextualize the adherence to the Prontuário Eletrônico do Cidadão (PEC - Citizen's Electronic Health Record) by Brazilian municipalities and the evolution of the electronic strategy of the Unified Health System (e-SUS) for Primary Healthcare (PHC) during its 10 years.

METHODS

This descriptive study added information on adherence to the use of medical records extracted from the database of the Secretaria de Atenção Primária à Saúde (SAPS- Primary Healthcare Secretary) of the Federal Government between 2017 and 2022. We analized the number of computerized basic healthcare units that used some electronic medical records, the number of those that used simplified data collection (SDC), and those that implemented the citizen's electronic health record (PEC) in the same period. A descriptive synthesis of the functionalities and modules implemented in the system during its 10 years of development was also carried out.

RESULTS

The adherence of Brazilian municipalities to the PEC has grown exponentially in the last five years, going from 8,930 healthcare units in 2017 to 26,091 in 2022. As expected, while the main functionalities and improvements developed in this decade sought to implement new flows and modules of administrative, clinical care, and care management processes and health service administration, improving aspects of usability and technological infrastructure of the application architecture was also crucial for the success of the system.

CONCLUSIONS

In 2023, the milestone of a decade will be celebrated since the beginning of health records implementation by Brazilian municipalities, marked by technological and infrastructure challenges and improvements and new functionalities that highlight the technological evolution of the e-SUS PHC system and strategy. Despite many other tools, the PEC is arguably Brazil's leading electronic medical record today, as it has always invested in evolution, updating itself in technological and usability opportunities.

[Evaluation of the impact of the implementation of the new primary health care information system on records of patient care and home visits in Brazil]

The replacement of the Primary Care Information System (SIAB, 1998-2015), as of January 2016, by the new Health Information System for Primary Care (SISAB) determined new forms of collecting, processing, and using information, with a possible impact on the records of activities carried out in primary health care in Brazil. This study aimed to evaluate the implementation impact of the new information system on records of physicians' and nurses' patient care and home visits of community health workers (CHW) in Brazil from 2007 to 2019. To this end, a Bayesian structural time-series model approach was used, based on a diffuse state-space regression. From 2016 to 2019, 463.47 million physician care, 210.61 million nursing care, and 1.28 billion CHW visits were recorded. Following the trend recorded before the implementation, 598.86 million, 430.46 million, and 1.5 billion physician and nursing appointments and CHW visits would be expected, respectively. In relative terms, there was a decrease of 25% in physician care, 51% in nursing care, and 15% in CHW visits when compared to the value expected by the Bayesian method. The negative impact on the records of patient care and home visits identified in this study, whether due to difficulties in adapting to the new system or a reduction in improper records, must be investigated so that the challenge of improving the primary care information system can be understood and overcome in a planned way.

Association between hospitalizations for sensitive conditions and quality of primary care

OBJECTIVE

To analyze the association between municipal rates of ambulatory care sensitive conditions (ACSC) hospitalization and the quality of primary health care (PHC), socioeconomic, and demographic variables and those related to local characteristics of the health system from 2010 to 2019.

METHOD

Ecological time series study in Brazilian municipalities analyzing the correlation of ACSC hospitalization rates with PHC quality measured by the three cycles of the Primary Care Access and Program for improving primary care access and quality (PMAQ-AB). The study included municipalities whose teams participated in 80% or more of at least two PMAQ-AB cycles. The correlation between standardized ACSC hospitalization rates and PHC quality and other variables was analyzed. Spearman's test was used between the response variable and numerical explanatory variables. Generalized equations estimation was used as a multivariate model associating ACSC hospitalization rates with the other variables over the years.

RESULTS

A total of 3,500 municipalities were included in the models. The quality of PHC (PMAQ-AB score) showed an inverse association with the variation in ACSC hospitalization rates. Hospitalization rates fell by -2% per year every ten-point increase in the PMAQ-AB score, adjusted by the remaining variables. A one-unit increase in the beds per 1,000 inhabitants variable had an impact of approximately +6.4% on ACSC hospitalization rates. Regarding population size, larger municipalities had lower ACSC hospitalization rates. Increased PHC coverage and lower socioeconomic inequality were also associated with the reduction in hospitalizations.

CONCLUSIONS

The reduction in ACSC hospitalization rates over time was associated with an increase in the quality of PHC. It was also associated with a reduction in the number of hospital beds and municipalities with better socioeconomic indicators.

Association between contextual factors and coverage of the Acwy meningococcal vaccine, after three years of its overdue, in the vaccination calendar of adolescents in the state of Minas Gerais, Brazil: global space regressions

The objective of the study was to analyze the spatial distribution of vaccination coverage of bacterial meningitis vaccine: A, C, W and Y (menacwy) and identify the association between socioeconomic and social environment factors with menacwy vaccine coverage among adolescents in the state of Minas Gerais (MG), Brazil. This is an ecological, mixed study, conducted with secondary data from the 853 municipalities of the State of MG, Brazil, from 2020 to 2022, provided by the information system of the National Immunization Program. For spatial statistical analysis, spatial dependence and the presence of spatial clusters formed by municipalities with high and low vaccination coverage of Menacwy were evaluated. In the year 2021, MG presented the largest vaccination coverage (60.58%) since the introduction of the Menacwy vaccine by the PNI. Regarding the analysis of global regressions, it is observed that for the year 2020, as the MG Index of Social Responsibility-Health increased and MG Index of Social Responsibility-Public Security increased, increased the vaccination coverage of the municipalities of the Menacwy vaccine. Finally, compared to 2021, similar association was observed in relation to the proportion of the population served by the Family Health Strategy of the municipalities of the state of MG and per capita spending on education activities: as this indicator increased, with increased coverage of the Vaccine of the Menacwy vaccine of the state municipalities. They reinforce the importance of assessing the quality-of-care management and health surveillance system, professional training, and damage reduction to populations, especially adolescents.

Food and nutrition actions for the maternal and child population in primary healthcare: comparative analysis of municipalities in the Metropolitan Region of Baixada Santista, São Paulo, Brazil

ABSTRACT Objective Characterize and comparatively analyse the organization of nutritional attention to prenatal care, the puerperium period and breastfeeding, in primary health care, in two municipalities of Baixada Santista, São Paulo, Brazil. Methods This was an exploratory-analytical study of family health units and the mixed basic care units of Cubatão (n=17) and Guarujá (n=14). For this purpose, seven domains of the Nutritional Attention Assessment Instrument in Primary Health Care were used. Descriptive analysis and the Mann-Whitney and Pearson’s chi-square tests were performed. Results In the comparison between the municipalities, the best scores were obtained in Guarujá. Statistically significant differences were found for the following indicators: support for nutritional attention actions: infrastructure and permanent education (<0.001); food and nutritional surveillance (<0.001); nutritional attention focused on prenatal care (<0.001); and nutritional attention focused on postpartum care and breastfeeding (0.012). Nutritional attention actions for mother-infant groups were more frequent in the city of Guarujá, which compared with Cubatão, achieved better scores for the nutritional attention evaluation indicators. Conclusion The municipality of Guarujá had better indicators of infrastructure and permanent education, food and nutrition surveillance, and puerperal and breastfeeding nutritional care. However, weaknesses persist in the organization of nutritional care in the two cities studied, especially regarding the work process.

The quality of alternative models of primary health care and morbidity and mortality in Brazil: a national longitudinal analysis

Background

Evidence is limited on health benefits from quality improvement of primary healthcare (PHC) in low- and middle-income countries (LMICs). This study investigated whether increasing PHC quality in Brazil with highly-skilled health professionals and integrated community health workers (CHWs) was associated with reductions in hospitalizations and mortality beyond benefits derived from increasing access.

Methods

Annual municipal-level data for 5,411 municipalities between 2000 and 2014 were analysed using fixed effects panel regressions. PHC quality was measured as: i) the proportion of consultations provided by highly-skilled health professionals (doctors and nurses); and ii) the proportion of visits provided by CHWs from multidisciplinary PHC teams. Models assessed associations between PHC quality and hospitalization and mortality from diabetes, cardiovascular disease (CVD), tuberculosis, leprosy, perinatal and maternal causes, and adjusted for PHC access, utilisation, presence of secondary care services, and socioeconomic factors.

Findings

A one percentage point increase in the proportion of consultations provided by highly-skilled health professionals was associated with 0•019 fewer deaths from diabetes per 100,000 population (95%CI: -0•034, -0•003; p-value: 0.0167) and 0•029 fewer hospitalizations per 100,000 from leprosy (95%CI: -0•055, -0•002; p-value: 0.0321). A one percentage point increase in the proportion of care provided by CHWs from multidisciplinary PHC teams was associated with 0•025 fewer deaths from CVD per 100,000 (95%CI: -0•050, -0•001; p-value: 0.0442) and 0•148 fewer maternal hospital admissions per 100,000 (95%CI: -0•286, -0•010; p-value: 0.0356). No significant associations were found for the other twenty pairs of exposures and outcomes analysed.

Interpretation

Investing in higher-quality PHC models with highly-skilled health professionals and integrated CHWs can deliver reductions in mortality and hospitalizations in LMICs.

Funding

None.