Pediatric hospitalizations for bronchiolitis in Brazil: longitudinal characterization and hospital costsAbstract
Objective To assess the longitudinal distribution of the number of pediatric hospitalizations for acute viral bronchiolitis in the Brazilian Health System and the expenses with hospitalizations corresponding to each macro-region at the Brazilian national level.
Methods This is a quantitative, observational, ecological study based on a retrospective and longitudinal analysis of data from the Brazilian Health System Information Technology Department from 2012 to 2021, using descriptive statistics and Tukey’s paired test.
Results There was a statistically significant difference regarding hospitalization costs in macro-regions at the national level over the years (p=0.017), but Tukey’s multiple comparisons indicated that there was no significant difference between 2 consecutive years, when comparing the years 2020 and 2021 and the mean value of hospitalizations by regions. The mean proportions of the number of hospitalizations in the macro-regions in the 10 years of study were 461.1 in the Midwest, 528.27 in the North, 1,026 in the South, 1,127 in the Northeast and 3,044 in the Southeast, considering that the highest incidence in terms of the mean of hospitalization was in the Southeast and there was a statistically significant difference in the number of hospitalizations over the years (p=0.001).
Conclusion There was a significant increase in the occurrence of hospitalizations for cases of acute viral bronchiolitis in children under 4 years old, especially in infants, which showed an increasing incidence of hospitalizations in this age group and hospital expenses in Brazil in most macro-regions, mainly in the Southeast.
Bronchiolitis viral; Respiratory syncytial viruses; Child; Intensive care units, pediatric; Hospitalization; Unified Health System
Resumo
Objetivo Avaliar a distribuição longitudinal do número de hospitalizações pediátricas por bronquiolite viral aguda no Sistema Único de Saúde e os gastos com internações correspondentes a cada macrorregião, no âmbito nacional brasileiro.
Métodos Estudo quantitativo, observacional, ecológico, tendo por base uma análise retrospectiva e longitudinal de dados do Departamento de Informática do Sistema Único de Saúde no período de 2012 a 2021, por meio de estatística descritiva e teste pareado de Tukey.
Resultados Houve diferença estatística significante quanto aos gastos das internações nas macrorregiões no âmbito nacional ao longo dos anos (p=0,017), porém as comparações múltiplas de Tukey indicaram que não houve diferença significante entre 2 anos consecutivos, quando comparados os anos de 2020 e 2021 e o valor médio de internações por regiões. As proporções médias dos números de internações nas macrorregiões nos 10 anos do estudo foram de 461,1 no Centro-Oeste, 528,27 no Norte, 1.026 no Sul, 1.127 no Nordeste e 3.044 no Sudeste, considerando que a maior incidência quanto à média de internação esteve no Sudeste e houve diferença estatística significante do número de internações ao longo dos anos (p=0,001).
Conclusão Houve aumento significativo da ocorrência de internações dos casos de bronquiolite viral aguda em crianças menores de 4 anos, especialmente em lactentes, o qual se mostrou crescente a incidência de internações nessa faixa etária e os gastos hospitalares no Brasil na maioria das macrorregiões, principalmente na Sudeste.
Bronquiolite viral; Vírus sinciciais respiratórios; Criança; Unidade de terapia intensiva pediátrica; Hospitalização; Sistema Único de Saúde
Resumen
Objetivo Evaluar la distribución longitudinal del número de hospitalizaciones pediátricas por bronquiolitis viral aguda en el Sistema Único de Salud y los gastos de internaciones correspondientes a cada macrorregión, en el ámbito nacional brasileño.
Métodos Estudio cuantitativo, observacional, ecológico, que tuvo como base un análisis retrospectivo y longitudinal de datos del Departamento de Informática del Sistema Único de Salud durante el período de 2012 a 2021, mediante estadística descriptiva y prueba pareada de Tukey.
Resultados Hubo diferencia estadística significativa respecto a los gastos de las internaciones en las macrorregiones en el ámbito nacional a lo largo de los años (p=0,017). Sin embargo, las comparaciones múltiples de Tukey indicaron que no hubo diferencia significativa entre dos años consecutivos al comparar los años 2020 y 2021 y el valor promedio de internaciones por regiones. La proporción promedio del número de internaciones en las macrorregiones en los diez años del estudio fue 461,1 en el Centro-Oeste, 528,27 en el Norte, 1.026 en el Sur, 1.127 en el Nordeste y 3.044 en el Sudeste, considerando que la mayor incidencia respecto al promedio de internaciones fue en el Sudeste y hubo diferencia estadística significativa del número de internaciones a lo largo de los años (p=0,001).
Conclusión Hubo un aumento significativo de internaciones de casos de bronquiolitis viral aguda en infantes menores de 4 años, especialmente lactantes, por lo que la incidencia de internaciones de este grupo de edad se mostró creciente, al igual que los gastos hospitalarios en Brasil en la mayoría de las macrorregiones, principalmente en la región Sudeste.
Bronquiolitis viral; Virus sincitiales respiratórios; Niño; Unidades de cuidado intensivo pediátrico; Hospitalización; Sistema Único de Salud
Introduction
Acute viral bronchiolitis is a disease with a significant incidence in the first years of life, and its main cause is associated with infectious processes in the lower respiratory tract in children under 2 years old. It is caused by the respiratory syncytial virus and is considered the main cause of hospital admission increase in Brazil, taking into account increased incidence of cases in children under 2 years old.1,2
Climate variability and an increase in cases of acute viral bronchiolitis are associated with respiratory syncytial virus. In some regions with temperate climates, infections occur predictably in outbreaks every year and last for 4 to 6 months, starting from the end of October to the beginning of spring, which may vary according to regions, country or state.3-6
The climatic profiles of many regions are considered relevant when compared to increase in pediatric hospitalizations in some seasons of the year, as the demand for pediatric care and waiting times in emergency care units can be observed in hospital settings.
Approximately 0.5% to 2% of previously healthy infants infected with respiratory syncytial virus require hospitalization, and for approximately 0.5% to 1%, hospitalization will occur in an Intensive Care Unit with the use of mechanical ventilation. Acute viral bronchiolitis generates, on average, 3 to 4 million hospitalizations/year. In the United States, spending on hospitalizations for acute viral bronchiolitis in children under 2 years old exceeded US$1.7 billion in 2009. Considering that the highest hospitalization rates occur in children between 30 and 60 days old, that an average of 22.8 emergency visits are made due to clinical conditions associated with acute viral bronchiolitis due to respiratory syncytial virus for every thousand infants and that 29% required hospitalization, accounting for an annual expenditure of US$650 million on hospitalizations in 2003.7-10
The viruses that cause the disease are defined as seasonal so that many viral agents can provide a correlation with the disease, such as adenovirus, parainfluenza, rhinovirus, human metapneumovirus, coronavirus, Mycoplasma pneumoniae. However, the highest viral incidence of acute viral bronchiolitis is associated with respiratory syncytial virus, which contributes significantly to increased number of hospitalizations and impacts pediatric patients’ clinical evolution, associated with the likelihood of using high-cost therapies and longer hospital stays due to the complexity of the disease.6,11-14
However, the impact of hospital costs due to acute viral bronchiolitis is associated with several factors, such as comorbidities, clinical deterioration, applicability of therapeutic approaches, such as inhalation, oxygen, use of invasive and drug therapies (e.g., corticoids and antibiotics), with annual direct cost of approximately US$394 million.15
Since pediatric comorbidities and external factors can impact the clinical evolution of acute viral bronchiolitis and its clinical outcome, consequently there will be greater scope in terms of the impact of hospital costs during hospitalization and longer patient stays.
Therefore, this study aimed to assess the longitudinal distribution of the number of pediatric hospitalizations due to acute viral bronchiolitis in the Brazilian Health System (SUS – Sistema Único de Saúde) and the expenses with hospitalizations corresponding to each macro-region within the Brazilian national scope.
Methods
This is a quantitative, observational, ecological study, based on retrospective and longitudinal analysis of data from the Brazilian Health System Department of Informatics (DATASUS - Departamento de Informática do Sistema Único de Saúde), study design was guided by the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE). The SUS Hospital Information System (SIH-SUS - Sistema de Informações Hospitalares do SUS) database was used for national data and data collections were obtained from the DATASUS electronic address, by accessing the Health Care, Care Network and Epidemiology and Morbidity directories section of the Health Information – TabNet section, in which there is no access to clinical data, only to the number of hospitalizations, which can be stratified by age group and place of service. As it is an open access platform, it was possible to access information on the absolute number of hospitalizations in the public health system.
The population was made up of pediatric patients under 1 year old and 1 to 4 years old, according to secondary data from the information system available on DATASUS. Data were collected between 2012 and 2021.
Data extraction was automated with the development of an application written in Java, capable of connecting via the HTTP protocol with the hospital production tables (SIH-SUS) from TabNet/DATASUS. Temporary internal identification numbers for procedures in SIH-SUS were manually searched.
Through a loop involving the collection period of interest and for each procedure, a POST request was made to the address http://tabnet.DATASUS.gov.br/cgi/tabcgi.exe, containing production arguments (SIH-SUS), table type (“Brazil by Region and Federation Unit”), line (“Year/month service”), column (“Region”), increment, year, month and, finally, procedure and format (table). For each procedure, three requests were made to SIH-SUS, for each increment, or two requests, if it belonged to SIH-SUS, for each increment.
For each request, the DataSus TabNet server returned an HTML file containing the tabulated data. Each file was syntactically analyzed by the application, which extracted each data from the table and saved it in an array containing the values of interest.
Once table analysis was completed, arrangement was saved in a character string variable, prepared in the comma-separated values (CSV) format. After covering all the years of the search, the application exported the CSV variable, containing all the data to a single file. Simultaneously with the collection stage, the data were entered in double entry by independent researchers into statistical and descriptive analysis software, and any discrepancies were reviewed and corrected.
Data (response variables: mean value of hospitalizations and number of hospitalizations per macroregion) were summarized using descriptive statistics, mean, standard deviation, sum of data, minimum value, maximum value and median, according to the factors of variation (independent variables), i.e., by year and by region.
Data were tabulated in an electronic spreadsheet and transferred to Minitab statistical software (version 18.1). To obtain the results, a level of statistical significance was adopted for p-values≤0.05.
The analysis to verify the impact of the independent variables for each response variable was carried out using a variance analysis model, considering the four variation factors as well as the interaction between “Year” and “Region”, indicated by “Year*Region”.
Whether for the interaction factor or for any of the other individual factors, in the case of statistical significance, Tukey’s multiple comparison technique was added, in addition to a 95% Confidence Interval, to identify which factor levels showed significant differences between each other.
Based on the results evidenced in the number of hospitalizations by macro-region and the mean value of hospitalizations for acute viral bronchiolitis at the national level, the epidemiological information was analyzed according to the classifiers available in DATASUS.
The methodological procedures of this research involve the restricted use of secondary and publicly accessible data (DATASUS database), i.e., data that is not subject to privacy, safety or access control limitations and is available without restriction access for researchers and the general population, in accordance with Law 12.527 of November 18, 2011.16
In research that uses this type of data, according to Resolution 510 of April 7, 2016 of the Brazilian National Health Council (CNS - Conselho Nacional de Saúde), they do not need to be registered or assessed by the Research Ethics Committee/Brazilian National Research Ethics Commission (REC/CONEP (Comissão Nacional de Ética em Pesquisa)) system.17
Results
By applying the statistical tests provided for comparing independent variables, such as the number of hospitalizations by macro-regions and the mean value of the Hospital Admission Authorization, it was possible to demonstrate, from 2012 to 2021, in DATASUS, that pediatric hospitalizations with diseases of the respiratory system (CIDJ21) that covered a diagnosis of acute bronchiolitis had demographic variability, according to the profile of each region assessed in the research, and the total number of hospitalizations in the period was 247,495 occurrences with the respective diagnosis of acute viral bronchiolitis. There was a statistically significant difference regarding the behavior of the mean value of Hospital Admission Authorizations between the regions over the years (p=0.017), but Tukey’s multiple comparisons indicated that there was no significant difference between 2 consecutive years when comparing the years 2020 and 2021 and the mean value of hospitalizations by regions. The proportions of the mean number of general hospitalizations for pediatric acute viral bronchiolitis in the macro-regions in the last 10 years were 461.1 in the Midwest, 528.27 in the North, 1,026 in the South, 1,127 in the Northeast and 3,044 in the Southeast, considering that the highest incidence in terms of mean hospitalization is located in the Southeast (Table 1).
Based on the data presented in Table 2, it is possible to observe that the mean values of pediatric hospitalizations in children under 4 years old in the macro-regions were R$2,934.4 to R$3,900.00. The minimum median of the macro-regions was R$3,014 and the maximum, R$3,422.5 between regions, and the sum of hospitalization values showed the metric of R$1,289.60 to R$13,739.
According to the distribution by region, it was observed that the highest incidence of mean hospitalization values due to a diagnosis of acute bronchiolitis was located in the Southeast and the lowest proportion of financial impact of mean hospitalization values was directed to the North, being the mean hospitalization value of R$2,934.4, which shows a significant statistical difference (p=0.017) regarding the behavior of the mean value of Hospital Admission Authorizations between Brazilian regions from 2012 to 2021.
Discussion
In this ecological study, the main finding was the variability in the number of hospitalizations and spending on hospital admissions between the macro-regions of pediatric patients admitted with a diagnosis of bronchiolitis during the research period, which may be associated with comorbidity and clinical deterioration in admission or during hospitalization in the hospital.
It is worth noting that Hospitalization for Primary Care-Sensitive Conditions represent a range of conditions for which access and effectiveness of primary care can reduce the probability of hospital admission, being considered an indicator of performance of Primary Health Care services.18
Among the Primary Care-Sensitive Conditions, we can highlight acute bronchiolitis as one of the diseases that is inserted in the respective context, which reinforces the implementation of public policies to reduce the diseases and expenses related to the period of hospitalization and length of hospital stay.
Among the acute respiratory syndromes of the lower respiratory tract, bronchiolitis is still considered responsible for many hospitalizations in infants. In developing countries, the number of deaths from the disease has been decreasing; however, children with comorbidities, such as immunodeficiencies and chronic lung diseases or congenital heart diseases, present a more serious condition, increasing disease lethality. 1,2,10,11
Reinforcing the importance of directing public health financial and technological resources in a more comprehensive way, in addition to professional qualification and family guidance regarding the early identification of signs and symptoms of bronchiolitis in infants, there was an improvement in quality of care for pediatric patients in primary and hospital healthcare, thus contributing to reducing the severity of the disease and hospital expenses.
Since bronchiolitis is on the Brazilian list of Hospitalization for Primary Care-Sensitive Conditions and occupies a large number of hospital admissions in children under 1 year old, followed by the age range of 1 to 4 years as presented in the DATASUS database, it becomes possible to highlight discrepancies between the number of hospitalizations and hospital expenses in distributions of macro-regions.
Study carried out to assess the performance of child health indicators and pediatric hospitalization rates show that high rates of child hospitalization in children under 5 years old are due to respiratory diseases. Most of these hospitalizations are avoidable, being called Hospitalization for Primary Care-Sensitive Conditions, since timely and quality outpatient care could solve the majority of children’s health problems, avoiding this outcome.19
In a study carried out to assess hospital morbidity in children under 5 years old and the main causes of pediatric hospitalizations, it was shown that, although there are several pathologies that can compromise children in this age group, the highest incidence is respiratory diseases. Of 342 pediatric hospitalizations assessed, 217 pediatric patients corresponded to the diagnosis of respiratory system diseases.16This shows that the distribution of hospital admissions for acute viral bronchiolitis and hospitalization costs are very varied.
There are macro-regions in which the distribution of hospitalizations is smaller when compared to others, such as the South, which had a median of 474 hospitalizations from 2012 to 2021, compared to the Southeast, which had a median of 1,978 for the pediatric population of children under 5 years old included in the research.
A study carried out at the national level to assess the impact of pediatric hospitalizations due to COVID-19 showed a decrease of more than 70% in hospital admissions for acute viral bronchiolitis in babies under 1 year of age across the country in 2020, which supports the evidence of the metrics assessed in this research.18
Even so, we had a growing curve in hospital expenses in the periods before the pandemic for children under 4 years old, with a total of R$117,375 to R$155,993. However, when compared to international literature, the estimated cost was up to US$545 million in the United States and the incidence was approximately 34 million new cases worldwide.5,7,9,18-20
Finally, it was possible to highlight significant variations in the number of hospitalizations and hospital expenses in macro-regions at the national level, which reinforces the implementation of public policies and early preventive actions so that additional expenses to the health system and the number of hospitalizations can be reduced.
There is a need to implement public policies, strategies for early identification of the disease’s evolution and preventive measures associated with the cessation of external factors that trigger the worsening of acute viral bronchiolitis, contributing to improving child health care quality and reducing the incidence of new cases and hospital costs for acute treatment of acute viral bronchiolitis.
The possible weakness in disease classification linked to the reason for hospitalizations due to Acute Viral Bronchiolitis (AVB), underreporting of care provided in the public and private system, lack of information in its entirety on the platform and changes in the parameterization of information are limitations of this study.
Conclusion
There was a significant increase in the occurrence of hospitalizations for cases of acute viral bronchiolitis in children under 4 years old, especially in infants, which showed an increasing incidence of hospitalizations in this age group and hospital expenses in Brazil in most macro-regions, mainly in the Southeast.
References
- 1 Del Toro Rodríguez LB, Martínez Benítez I, Martínez Morales I, Garcia Aguilera A, Diéguez Avid MA. Caracterización clínica-epidemiológica de las Bronquiolitis en pacientes pediátricos. Multimed (Granma). 2021;25(2):e1448.
- 2 Tan J, Wu J, Jiang W, Huang L, Ji W, Yan Y, et al. Etiology, clinical characteristics and coinfection status of bronchiolitis in Suzhou. BMC Infect Dis. 2021;21(1):135.
- 3 Alnajjar AA, Dohain AM, Abdelmohsen GA, Alahmadi TS, Zaher ZF, Abdelgalil AA. Clinical characteristics and outcomes of children with COVID-19 in Saudi Arabia. Saudi Med J. 2021;42(4):391-8.
- 4 House SA, Marin JR, Hall M, Ralston SL. Trends over time in use of non-recommended tests and treatments since publication of the American Academy of Pediatrics Bronchiolitis Guideline. JAMA New Open. 2021;4(2):e2037356.
- 5 Mejias A, Ramilo O. Defining the burden of respiratory syncytial virus infection. J Pediatr (Rio J). 2013;89(6):517-9.
- 6 Hall CB, Weinberg GA, Bulking AK, Edwards KM, Staat MA, Schultz AF, et al. Respiratory syncytial virus-associated hospitalizations among children less than 24 months of age. Pediatrics. 2013;132(2):e341-8.
- 7 Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2017;389(10065):211-24.
- 8 Vieira SE, Stewien KE, Queiroz DA, Durigon EL, Török TJ, Anderson LJ, et al. Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in São Paulo, Brazil. Rev Inst Med Trop Sao Paulo. 2001;43(3):125-31.
- 9 Meissner HC. Viral Bronchiolitis in Children. N Engl J Med. 2016;374(1):62-72.
- 10 Borges AM, Schaan CW, Amantéa SL, Lukrafka JL. Ventilação mecânica não invasiva na bronquiolite viral aguda: estudo de coorte retrospectivo. Cien Saude. 2017;10(4):232-8.
- 11 Naves KC. Análise crítica do tratamento instituído a crianças com infecção por vírus sincicial respiratório em um hospital público [dissertação]. São Paulo: Faculdade de Medicina da Universidade de São Paulo; 2018.
- 12 Carvalho WB, Johnston C, Fonseca MC. Bronquiolite aguda, uma revisão atualizada. Rev Assoc Med Bras 2007;53(2):182-8. Review.
- 13 Bekhof J, Wessels M, Ten Velde E, Hoekstra M, Langenhorst V, Bruijnesteijn L, et al. Room sharing in hospitalized children with bronchiolitis and the occurrence of hospital-acquired infections: a prospective cohort study. Hosp Pediatr. 2019;9(6):415-22.
- 14 Susana Rodríguez M. Bronchiolitis in the year of COVID-19. Arch Argent Pediatr. 2020;118(3):222-3.
- 15 Paramore LC, Ciuryla V, Ciesla G, Liu L. Economic impact of respiratory syncytial virus-related illness in the US: an analysis of national databases. Pharmacoeconomics. 2004;22(5):275-84.
- 16 Brasil. Lei n 12.527, de 18 de novembro de 2011. Regula o acesso a informações previsto no inciso XXXIII do art. 5º, no inciso II do § 3º do art. 37 e no § 2º do art. 216 da Constituição Federal; altera a Lei nº 8.112, de 11 de dezembro de 1990; revoga a Lei nº 11.111, de 5 de maio de 2005, e dispositivos da Lei nº 8.159, de 8 de janeiro de 1991; e dá outras providências. Diário Oficial da União, Brasília (DF), 18 nov. 2011.
- 17 Brasil. Resolução n 510, de 07 de abril de 2016. Ética na Pesquisa na área de Ciências Humanas e Sociais. Diário Oficial da União, Brasília (DF), 24 mai. 2016.
- 18 Dias BM, Ballestero JG, Zanetti AC, Machado GA, Bernardes A, Gabriel CS. Expenses with hospitalizations by sensitive conditions to the primary care: an ecological study. Acta Paul Enferm. 2022;35:eAPE039001134.
- 19 Ledbetter J, Brannman L, Wade SW, Gonzales T, Kong AM. Healthcare resource utilization and costs in the 12 months following hospitalization for respiratory syncytial virus or unspecified bronchiolitis among infants. J Med Econ. 2020;23(2):139-47.
- 20 Ruiz-Silva M, Hernández-Pérez I, Montes-de-Oca-Domínguez M. Comportamiento clínico-epidemiológico de la bronquiolitis aguda en lactantes admitidos. Belmopán, Belice. 2015. Mul Med. 2017;21(3):174-89.
Edited by
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Associate Editor
Myriam Aparecida Mandetta (https://orcid.org/0000-0003-4399-2479) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brasil
