Structure and work process in primary care and hospitalizations for sensitive conditions

Araujo, Waleska Regina Machado; Queiroz, Rejane Christine de Sousa; Rocha, Thiago Augusto Hernandes; Silva, Núbia Cristina da; Thumé, Elaine; Tomasi, Elaine; Facchini, Luiz Augusto; Thomaz, Erika Barbara Abreu Fonseca

doi:10.11606/S1518-8787.2017051007033

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Original Articles • Rev. Saúde Pública 51 • 2017 • https://doi.org/10.11606/S1518-8787.2017051007033 copy

Structure and work process in primary care and hospitalizations for sensitive conditions

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions.

METHODS

In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (β) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%).

RESULTS

In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (β = -0.001) and private insurance (β = -0.01) had a negative association, and the human development index (β = 1.13), the proportion of older adults (β = 0.05) and children under the age of five (β = 0.05), and the coverage of the Community Health Agent Strategy (β = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (β = -0.14) and availability of vaccines (β = -0.16) showed a negative association, and availability of medications showed a positive association (β = 0.16). In the proximal level, only the variable of matrix support (β = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013.

CONCLUSIONS

The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities.

Primary Health Care, organization & administration; Patient Admission; Outcome and Process Assessment (Health Care); Program Evaluation; Ecological Studies

Indicator	Description	Source/Year
% of older adults in the population	Percentage of persons aged 60 years or over, in the total population living in a given geographical area, in the year considered.	Demographic Census (IBGE, 2010)
% of children under the age of five in the population	Percentage of persons aged 5 years or less, in the total population living in a given geographical area, in the year considered.	Demographic Census (IBGE, 2010)
Gini index of per capita household income	It measures the degree of concentration of the per capita household income distribution of a given population and in a given geographic space. The index varies from zero (0), perfect equality, to one (1), perfect inequality.	National Household Sample Survey – PNAD (IBGE, 2010)
Municipal Human Development Index (MHDI)	It is a measure composed of indicators of three dimensions of human development: longevity, education, and income. It varies from 0 to 1. The closer to 1, the greater the human development.	United Nations Development Programme – UNDP (2010)
Rate of coverage of private health insurance	Ratio between the number of beneficiaries of private health insurance and the population of the area, multiplied by 100.	National Health Agency (2010)
% of BHU in the municipality with ratio of physicians/team ≥ 1	The number of physicians was obtained by adding the physicians of the minimum and extended team of each BHU of the municipality, divided by the total number of teams in each unit. The indicator was then categorized to reflect the average percentage of BHU of the municipality with at least one physician per team.	Module I of cycle 1 of the PMAQ-AB (2012)
% of BHU in the municipality with minimal health team	It is recommended that the minimum team should be composed of physician, nurse, nursing assistant and technician, and four Community Health Agents (CHA)⁵. The minimum team indicator corresponded to the average percentage of BHU of the municipality with minimum teams.
% of BHU in the municipality operating at least the minimum hours	Hours of operation were considered minimum when the BHU operated at least two shifts a day, five days a week. An indicator was constructed for the municipality calculating the average percentage of BHU with minimum hours.
% of BHU in the municipality with availability of at least 75% of the 12 vaccines of the basic calendar	The availability of vaccines was estimated by the existence and availability of immunobiological agents advocated by the National Immunization Policy. The indicator corresponded to the average percentage of BHU that always had more than 75% of the 12 vaccines of the basic calendar. The cutoff point refers to the proportion of adequate coverage^a.
% of BHU in the municipality with 80% or more of the medications of the basic component of the National Essential Medicine List (RENAME)	The medications of the basic component of the RENAME were verified, in sufficient quantity (antiparasitics, multivitamins and minerals, antiasthmatics, hormones, antihypertensives and of cardiovascular action, antidiabetics, antibacterials, analgesics/antipyretics, treatment and prevention of osteoporosis, antacids/antiemetics/antisecretors). The indicator refers to the sum of medications available in sufficient quantity, divided by the total number of medications in the list, multiplied by 100. The cutoff point refers to the goal of 80% availability of medications^b.
% of PCT in the municipality responsible for the user’s referral to specialized care	Percentage of PCT that, when a user needs to be referred to a specialist, schedules and informs the date of appointment with the specialist to the user.	Module II of cycle 1 of the PMAQ-AB (2012)
% of PCT in the municipality with home visit	The indicator of home visit for the municipality represents the average percentage of teams that reported visits, taking into account the CHA and other team members.
% of PCT in the municipality with matrix support	The matrix support is a methodology of care management and is a technical and pedagogical support to teams⁶. This indicator represented the average percentage of teams that reported receiving support from other professionals to solve complex cases.
Rate of ICSAP^c	Ratio between the number of ICSAP and the population of the municipality per 10,000 inhabitants.	SIH-SUS (2012 to 2014), Demographic Census (IBGE, 2010)
Proportion of ICSAP^c	Percentage of ICSAP in relation to total hospitalizations in the municipality for each year.
Number of ICSAP^c	Absolute number of ICSAP.

Variable	x̄	SD	Q1	Med.	Q3	Min.	Max.
Distal level (municipality)
Gini Coefficient	0.5	0.07	0.4	0.5	0.5	0.3	0.8
MHDI	0.6	0.07	0.6	0.7	0.7	0.4	0.9
% population ≥ 60 years	12.1	3.3	9.9	12.1	14.2	2.6	29.4
% population < 5 years	7.4	1.8	6.2	7.2	8.3	2.3	19.4
Coverage of BFP	80.7	18.1	72.2	85.1	94.7	0	100
Coverage of EACS	90.2	23.2	100	100	100	0	100
Coverage of FHS	81.9	29.0	71.6	100	100	0	100
Coverage of private insurance	8.4	11.4	1.1	3.6	10.9	0.01	96.11
Intermediate level (BHU)
BHU ≥ 1 physician/team^a	81.8	26.9	69.8	100.0	100	0	100
Minimum team^b	65.0	32.0	45.0	66.7	100	0	100
Minimum hours^c	87.1	22.3	80.0	100	100	0	100
Availability of medications >80%^d	4.1	16.6	0	0	0	0	100
Availability of vaccines >75%^e	57.1	35.5	28.6	57.1	100	0	100
Proximal level (PCT)
Referral to specialist^f	56.6	43.0	0	66.7	100	0	100
With home visit^g	99.3	6.9	100	100	100	0	100
With matrix support^h	84.1	30.9	84.3	100	100	0	100

ICSAP	x̄	SD	Q1	Med.	Q3	Min.	Max.
Number of ICSAP (2012)	433.8	1643.1	57.0	155.5	434.0	1.0	88291.0
Number of ICSAP (2013)	428.0	1636.4	57.0	155.0	442.0	1.0	90379.0
Number of ICSAP (2014)	407.3	1582.8	53.0	142.0	414.0	2.0	88212.0
Rate of ICSAP/10,000 (2012)	169.2	128.5	77.5	132.9	224.9	0.9	997.9
Rate of ICSAP/10,000 (2013)	161.3	121.8	74.7	126.2	212.6	1.7	990.3
Rate of ICSAP/10,000 (2014)	154.3	122.1	69.1	116.9	202.2	1.4	960.9
Proportion of ICSAP (2012)	30.5	12.7	20.9	28.4	38.2	2,2	86.1
Proportion of ICSAP (2013)	29.9	12.5	20.6	27.7	37.3	1.7	84.8
Proportion of ICSAP (2014)	28.1	12.3	19.1	25.7	35.2	3.7	85.0

Variable	Number of ICSAP (2013)						Number of ICSAP (2014)

	Unadjusted			Adjusted			Unadjusted			Adjusted

	Coeff^a	95%CI^a	p^a	Coeff^a	95%CI^a	p	Coeff^a	95%CI^a	P^a	Coeff^a	95%CI^a	p^a
Distal level
Gini Coefficient	-0.10	-0.40–0.19	0.485				-0.27	-0.40–0.19	0.070.
MHDI	-0.06	-0.33–0.21	0.673.	1.13	0.69–1.57	< 0.001	0.08	-0.19–0.36	0.565	1.30	0.85–1.75	< 0.001
% > 60 years	0.04	0.03–0.04	< 0.001	0.05	0.04–0.06	< 0.001	0.04	0.03–0.04	< 0.001	0.05	0.04–0.06	< 0.001
% < 5 years	-0.03	-0.04– -0.02	< 0.001	0.05	0.03–0.07	< 0.001	-0.03	-0.04– -0.02	< 0.001	0.05	0.03–0.07	< 0.001
Coverage BFP	0.001	0.0001–0.002	0.029	-0.001	-0.002– -0.0001	0.033	0.001	0.0001–0.002	0.035	-0.001	-0.002– -0.0002	0.017
Coverage EACS	0.003	0.002–0.004	< 0.001	0.002	0.001–0.003	< 0.001	0.003	0.002–0.004	< 0.001	0.002	0.001–0.003	< 0.001
Coverage FHS	0.002	0.001–0.003	< 0.001				0.002	0.001–0.003	< 0.001
Coverage private insurance	-0.01	-0.01– -0.007	< 0.001	-0.01	-0.01– -0.01	< 0.001	-0.009	-0.01– -0.008	< 0.001	-0.01	-0.01– -0.008	< 0.001
Intermediate level
% BHU ≥ 1 physician/team^b	-0.02	-0.09–0.05	0.520				-0.02	-0.09–0.05	0.535
% BHU minimum team^c	0.04	-0.02–0.1	0.187				0.02	-0.04–0.08	0.461
% BHU minimum hours^d	-0.18	-0.26– -0.1	< 0.001	-0.14	-0.23– -0.06	0.001	-0.12	-0.21– -0.03	0.006	-0.09	-0.18– -0.01	0.035
% BHU ≥ 80% medications^e	0.14	0.03–0.26	0.016	0.16	0.04–0.27	0.007	0.16	0.04–0.28	0.006	0.17	0.05–0.28	0.004
% BHU ≥ 75% vaccines^e	-0.14	-0.20– -0.09	< 0.001	-0.16	-0.22– -0.11	< 0.001	-0.16	-0.21– -0.10	< 0.001	-0.18	-0.24– -0.13	< 0.001
Proximal level
% referral by FHS^g	-0.01	-0.07–0,05	0.684				-0.01	-0.07–0,05	0.827
% PCT home visit^h	0.19	-0.14–0.53	0.256				0.05	-0.33–0.44	0.777
% PCT matrix supportⁱ	0.11	0.03–0.20	0.009	0.10	0.02–0.19	0.015	0.09	0.004–0.18	0.041	0.07	-0.01–0.16	0.092

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[1] Correspondence: Waleska Regina Machado Araujo, Departamento de Saúde Pública, Universidade Federal do Maranhão. Rua Barão de Itapary, 155 Centro 65020-070 São Luís, MA, Brasil. E-mail: waleska_regina@hotmail.com