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Conteúdo (article):

Accessibility and care pathways for children admitted to hospital for ambulatory care sensitive conditions

Acessibilidade e trajetórias de cuidado para crianças com internações por condições sensíveis à atenção primária

Harley Medawar Leão – Mestre em Ciências da Saúde
Universidade Estadual de Montes Claros (Unimontes). Programa de Pós-Graduação em Ciências da Saúde. Montes Claros, Minas Gerais, Brasil.
E-mail: harleymedawar@gmail.com
ORCID: https://orcid.org/0000-0002-7960-0214

Antônio Prates Caldeira – Doutor em Ciências da Saúde (autor correspondente)
Universidade Estadual de Montes Claros (Unimontes). Programa de Pós-Graduação em Ciências da Saúde. Montes Claros, Minas Gerais, Brasil.
E-mail: antonio.caldeira@unimontes.br
ORCID: https://orcid.org/0000-0002-9990-9083

Resumo
Objetivou-se analisar a acessibilidade e trajetórias de cuidado para crianças com internações por condições sensíveis à atenção primária (ICSAP). Trata-se de estudo transversal de internações selecionadas ao longo de um ano, em cidade do norte de Minas Gerais. Utilizou-se o Instrumento de Avaliação da Atenção Primária (PCA-Tool Brasil, versão criança), para aferir a acessibilidade e entrevistas com os cuidadores para definição detalhada do percurso familiar até a internação. Entre as 379 hospitalizações avaliadas, 109 (28,9%) foram classificadas como ICSAP. Os escores de acessibilidade e utilização dos serviços de saúde foram baixos tanto para as ICSAP como para as demais internações e sem diferenças estatisticamente significantes (p<0,05). As trajetórias de cuidado revelam que a maioria das famílias procurou primeiramente o hospital, sendo frequente a busca por vários serviços de saúde, antes da hospitalização. Em 63,3% dos casos de ICSAP, as famílias não procuraram a atenção primária em nenhum momento. A acessibilidade se mostrou comprometida para o grupo estudado, independente do motivo que gerou a internação e as trajetórias de cuidado revelaram um padrão irregular de utilização dos serviços de saúde para crianças com ICSAP, sugerindo uma rede assistencial frágil.
Palavras-chave: Acesso aos serviços de saúde; Atenção primária à saúde; Saúde da criança.


Abstract:
The aim of this study was to analyze health service accessibility and the care pathways of children admitted to hospital for ambulatory care sensitive conditions (ACSCs). A cross-sectional study was conducted of a random sample of children hospitalized over a period of one year in a town in the north of Minas Gerais, Brazil. The Primary Care Assessment Tool Child Edition, adapted and validated for use in Brazil (PCAT-CE), was used to assess accessibility and interviews were conducted with the children\'s carers to determine the pathway taken to hospitalization. Of the 376 pediatric hospitalizations assessed, 109 (28.9%) were classified as ACSC admissions. Health service accessibility and utilization scores were low for both the ACSC and non-ACSC groups. No statistically significant differences (p <0.05) were found between the two groups. The care pathways reveal that most families visited hospitals as the first service and that visits to other health services were frequent. Well over half (63.3%) of the families of children admitted for ACSCs did not seek primary health services at any time. Accessibility was poor among the study group, regardless of the reason that led to hospitalization. The care pathways reveal an irregular pattern of service utilization for children admitted for ACSCs, suggesting a fragile health care network.
Keywords: Access to health services; Primary health care; Children\'s health.

INTRODUTION

In recent decades, Brazil has witnessed substantial improvements in maternal and child health indicators1. Many of these improvements have been attributed to improved access to health services through the expansion of the country\'s Estratégia Saúde da Família or Family Health Program (FHP)2. However, a number of challenges remain, including high rates of preterm births and neonatal mortality, low rates of breastfeeding, and persistence of congenital syphilis1.

Hospitalization is an important issue in child health care because of the cost implications of hospital admission, family suffering, and health inequalities, with hospital admission rates being higher among children from poor families3. Part of admissions are due to shortcomings in ambulatory care. In this regard, the provision of adequate and timely treatment at the first level of care can avoid the clinical deterioration of the patient and reduce admissions for ambulatory care sensitive conditions (ACSCs)4.

ACSC lists present conditions that could be better managed by primary health care (PHC) teams and rates of admissions for ACSC may be considered an indicator of poor access to health services and/or poor care quality4. Recent evidence suggests that there is an association between ACSC admission rates and the expansion of FHP teams5-7. However, the majority of studies show ecological correlations, meaning that it is not possible to affirm unequivocally that the reduction in rates of admissions for ACSCs is due solely to the expansion of FHP teams. Certain factors that influence patterns of health service use are outside the scope of PHC, thus making it more difficult to assess the influence of the FHP as a determinant of ACSC admissions8,9.

Admissions for ACSCs among children are primarily due to acute conditions and questions therefore arise as to the capacity of PHC teams to avoid such admissions10. A study in the Northeast Region of Brazil reported that the proportion of hospitalizations due to the main groups of causes of sensitive conditions remained stable or increased despite an expansion of FHP teams, therefore suggesting that admissions are influenced by other factors11.

An analysis of the literature shows that there a number of gaps in knowledge of the association between ACSC admissions and improved access to health services through the FHP. One of these gaps is the need to obtain a fuller understanding of the path taken by children and their families from the onset of illness to hospitalization, referred to as the clinical pathway.

The assessment of clinical pathways is different to the evaluation of therapeutic itineraries, which takes an eminently qualitative approach, analyzing cultural aspects and social representations of the health-illness process. These evaluations often fail to consider questions such as access, service utilization, and patient-specific factors12. Studies of care pathways can therefore help enhance care by pointing out deficiencies along the pathway, bearing in mind that ACSC admissions are undesirable preventable outcomes. The objective of this study was to analyze accessibility and clinical pathways for children admitted to hospital for ACSCs.

METHODS
We conducted a cross-sectional study of a representative sample of pediatric hospital admissions over a period of one year in a town in the Southeast of Brazil. In 2017, the town had a population of approximately 400,000 inhabitants, 80 pediatric hospital beds in two public hospitals, and coverage of the FHP was over 80%.
The study population was defined as hospitalized children aged between zero and 10 years living in the town accompanied by parents/responsible persons during data collection. Children from other towns and whose companions were aged under 18 years were excluded.

The sample size was calculated based on the number of pediatric beds and admissions over the last year in both hospitals using a 95% confidence level, margin of error of 5%, and estimated ACSC admission prevalence of 40%. We added 10% to the minimum estimated sample size to account for possible losses and refusals, resulting in a final sample of 375 hospitalizations.

The data collection instrument was devised to obtain information on sociodemographic characteristics (age, sex, skin color, education, income, and town of origin), care (diagnoses, admissions history, services and professionals visited by the patient, and the patient’s health records), and “accessibility” and “primary care service utilization”. The items regarding accessibility and service utilization were taken from the Primary Care Assessment Tool Child Edition, adapted and validated for use in Brazil (PCAT-CE). The PCAT-CE assesses essential and derivative attributes of primary care on a scale of zero to 10, where a score of 6.6 is considered satisfactory13. The essential attribute used by this study was “first contact access”, which consists of the dimensions “accessibility” (with six questions) and “utilization” (with three questions).

The clinical diagnoses were collected from the patient\'s health records and coded according to the International Classification of Diseases, Tenth Revision (ICD-10). They were then classified into two groups (ACSCs and non-ACSCs) according to the Brazilian list of ambulatory care sensitive conditions6. The final list of ACSCs includes 20 groups of diagnoses and was elaborated by a group of health professionals, managers, and researchers4.
The sample of hospitalized children was selected using simple random sampling. The data was collected during hospital visits made in intervals of an average of seven days by a previously trained team consisting of a nurse and two nursing students. All children that met the inclusion criteria identified on each visit were selected. The data was collected between June 2016 and August 2017. This time period was used to avoid selection bias potentially caused by seasonal variations in disease. For quality control purposes, 20 randomly selected participants were reinterviewed to verify data reliability.

The data were analyzed using IBM SPSS (Statistical Package for the Social Sciences) version 22.0 for Windows. The proportions of the characteristics of each group (ACSCs and non-ACSCs) were compared using Pearson\'s chi-square test, while the mean accessibility scores and other means were compared using the Mann–Whitney U test. Data normality was tested using the Kolmogorov–Smirnov test. A significance level of 0.05 was adopted for all tests.

A detailed interview was conducted with the person responsible for each child to identify all points of health care visited and the time interval between the onset of the first symptoms and admission. Based on the results of these interviews, we developed a flow diagram of the care pathways of the children admitted to hospital for ACSCs. The clinical pathways were assessed to identify cases referred by the FHP and those who sought hospital services directly without referral.

The study was approved by Montes Claros State University\'s Research Ethics Committee (CAAE: 50473815.4.0000.5146 and code Nº. 1.312.447) and by the participating hospitals\' Teaching and Research Centers. All participants signed an informed consent form.

RESULTS

Of the 376 pediatric hospitalizations assessed, 109 (28.9%) were classified as ACSC admissions. The main causes of the admissions were “bacterial pneumonia” (45.9%), “kidney and urinary tract infections” (14.7%), “infectious gastroenteritis and complications” (11.0%), and bronchitis/asthma (11.0%).

In both groups, the responsible person was predominantly the child\'s mother and the large majority of the mothers were aged between 20 and 39 years and lived with the child\'s father. Only a small percentage of the fathers and mothers had at least 12 years of education and two-thirds of the families reported having an income of less than two minimum salaries. The only statistically significant difference between the groups was the percentage of male children, which was higher in the non-ACSCs group (p=0.003) (Table 1).

No significant differences were found in the mean time interval (in days) between the onset of symptoms and the first time that the patient visited health services and between the onset of symptoms and hospital admission between the two groups. The mean accessibility and utilization scores were below 6.6 and no statistically significant differences in scores were found between the groups (Table 2).

With regard to assessment of accessibility and utilization (Table 3), the only item that showed a statistically significant difference between the groups was difficulty getting medical care (p=0.045), with a larger percentage of respondents in the non-ACSC group reporting difficulties.

The analysis of the care pathways of hospitalized children who visited the FHP as the last service before admission showed that 53.8% were referred for ACSCs and 56.5% for non-ACSCs.

Figure 1 presents a synthesis of the care-seeking pathways reported by the respondents for ACSC admissions, revealing that most families visited hospitals as a first service (56.0%) and around one-third (32.1%) visited primary care centers. The findings also show that families frequently sought various services before hospitalization. PHC services were visited at some point during the care pathway up to hospitalization in 36.7% of the cases of ACSCs.

DISCUSSION

The findings show that the rate of admissions for ACSCs was high, suggesting that primary child care in the region studied is compromised. The percentage reported by the present study is lower than that reported by a previous study in the same town using the same methodology, which may be due to the expansion of coverage by family health teams10. Studies using an ecological approach have revealed that there has been a fall in the rate of admissions for ACSCs in recent years in Brazil, demonstrating that this reduction is associated with the expansion of the FHP5-7.

It is reasonable to assume that improved access results in the delivery of more timely care, thus having a positive impact on health indicators such as hospital admissions. Some authors have also highlighted that, in addition to improved access, the care model adopted by the FHP involves a change in clinical practices, resulting in more effective care, especially for patients with chronic conditions14. However, other studies stress that the use of admissions for ACSCs as an indicator of resolvability in PHC should be viewed with caution because it does not take into account socioeconomic factors linked to condition severity or specific aspects of the hospital admission process15-18.

The factors influencing admissions for ACSCs are complex and encompass patient-specific factors (socioeconomic deprivation) and factors relating to medical practice (lack of continuity of care) and hospital care (increased availability of hospital beds). Moreover, the rate of admission for ACSCs may vary depending on frequency of very short-stay admissions, inappropriate referrals, limited care options, bed availability, and government targets, making admissions for ACSCs “provision sensitive”9, 19.

The two dimensions used to assess first contact access received unsatisfactory scores13. No association was found between theses scores and type of classification of hospitalizations (ACSCs and non-ACSCs). To improve services, it is essential to recognize the limitations of ACSCs as an indicator of care quality and examine the influence of other factors on admission for ACSCs in this age group. The fact that no difference was found in access and utilization scores between the two groups means that we cannot confirm that these variables determine the effectiveness of FHP teams in avoiding hospitalizations.

The findings show that there was a statistically significant association between difficulty in getting medical care and admissions for ACSC. Difficulty in getting an appointment in the FHP may lead the family to seek other types of services, decharacterizing the organization of the service network and overburdening hospital services. Studies have also shown that difficulty in getting an appointment means that patients have to travel to other services, particularly hospital services20,21. Patients who seek treatment in hospitals and emergency departments, services that do not fall within primary care, are less likely to receive continuity of care. Seeking other services therefore undermines affiliation with the primary care source and comprehensiveness and leads to a lack of accountability and continuity.

A strong and resolutive primary care service requires facilitated access, whereby patients affiliated to care facilities are able to get an appointment when they need it scheduled according to the availability of the care team and patient. Other studies have highlighted deficiencies in access and quality issues in children\'s health services provided by the FHP and that the population tends to place more value on urgent care services over primary care22,23.

A study conducted in the south of Brazil using the PCAT reported that higher primary care quality scores in a setting with predominantly poor quality services that were not tailored to treat chronic conditions did not influence the rate of admissions for ACSCs24. A systematic review concluded that the association between increased coverage of the FHP and lower rates of admissions for ACSCs was not clear, demonstrating a lack of consensus in the literature and suggesting that the effect of the coverage of FHP in the country may be overestimated due to limited technical capacity and staff shortages25.

The data presented show that there were no significant differences between the groups in time intervals between the onset of symptoms and first contact with health services and admission to hospital. This shows that conditions that result in preventable hospitalizations are not being diagnosed and treated in a timely manner, as highlighted by other studies15. This reinforces the importance of obtaining a better understanding the pathways followed by families from the onset of symptoms to admission to hospital.

Our findings show that the situation is inconsistent with the model proposed by the health care network, with a low percentage of families seeking PHC services for all types of health problems. A study conducted in the United States assessing outpatient appointments before admission of children to hospital found similar results, with almost one-third of children not having had an outpatient appointment in the seven days prior to admission for ACSCs26. The fact that the majority of families of children admitted to hospital for ACSCs in the present study did not seek the FHP is an important problem, demonstrating that access to hospital services does not occur necessarily through primary care services, meaning that PHC is not fulfilling its role as coordinator of health care flow27.

The low percentage of families seeking FHP teams may be related to difficulties arising from opening hours, local factors, and factors related to health team work processes aimed at simultaneously meeting spontaneous demand and that of non-priority groups. However, it may also due to the personal choice of families to seek other services as the point of entry to the system based on past experiences and higher expectations in relation to resolvability28.

The pathways identified by this study suggest that families seem not understand the organization of the health system, demonstrating weak affiliation and lack of coordination of care by PHC services. Moreover, they seem to have little understanding of attributes such as continuity of care and comprehensiveness in the context of PHC, which are aspects that were reported by a previous study highlighting the need to promote greater adherence to these attributes of PHC by FHP teams29.

Our findings regarding the clinical pathways taken by the families also point to the need to discuss the quality of the care delivered by primary care services. In this regard, studies have shown that services where quality is less than ideal appear not to have an impact on admissions for ACSCs28. When all possible options open to the patient are not exhausted at the first level of care before referral to more complex levels, stages in the healthcare process end up being “skipped”, pointing to the failure of existing flows29. In these cases, the accountability of health professionals with patients, together with increased commitment, results in measures that are better tailored to patient needs.

Another questioned raised by this study is the apparent overprovision of hospital care. The unnecessary hospitalization of cases that could have been treated in primary care services leads to an interruption or discontinuity of primary care, which, to a certain degree, contributes to the aggravation of the disease. However, this question is beyond the scope of this study and demands further research.

The determinants of admissions for ACSCs during childhood are complex and include patient-specific factors and factors related to the first level of care and hospital admission trends18. The findings of this study show that the indicator admissions for ACSCs during childhood reveals the lack of organization of the health network in ensuring the continuity of quality children\'s health care.
This study has some limitations affecting the interpretation and generalization of the findings. First, despite being random and representative, the sample was restricted to only one town and to public hospitals. Second, during data collection, the participating hospitals\' pediatric units were undergoing refurbishment, resulting in the transferal of short-stay admissions to the emergency departments, which were not included in the analysis. However, the results are relevant and consistent with the literature, suggesting the need for a differentiated approach towards admissions for ACSCs during childhood.

In conclusion, accessibility of primary care for children requires improvement, regardless of the reason for admission to hospital. In addition, the pattern of service utilization by the families of the children admitted for ACSCs was irregular and this indicator suggests that there is a lack of continuity of quality children\'s health care.

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