Resumo (abstract):
Hospitalizations for ambulatory care sensitive conditions (ACSCs) are preventable with adequate primary care (PC). For the elderly population, they are important due to their greater vulnerability to chronic diseases and comorbidities. Objective: to carry out an integrative review of articles on ACSCs in the elderly and their correlation with indicators of access to primary care. The research was carried out on the BVS and PUBMED databases. Inclusion criteria: relationship between ICSAP and PA, publications2000 to 2022, analysis of the elderly age group, statistical methods, Portuguese, Spanish or English languages and indexing in peer-reviewed journals. Duplicate articles and those outside the criteria were excluded. We identified 315 publications and ed 15, 12 of which focused on the elderly population. The South and Southeast regions were the most analyzed, and the year most investigated was 2012. Coverage of the Family Health Strategy was the most commonly used indicator. The method most used for correlation was Pearson. A reduction in ACSC rates in the elderly was positively correlated with access to PHC. Monitoring ACSCs is an important tool for managing the health of the elderly, with PH playing a strategic role in reducing hospitalizations, minimizing risks and promoting healthy ageing.
Palavras-chave (keywords):
Ambulatory Care Sensitive Conditions; Hospitalization; Review; Aged; Health Status Indicators.
Ler versão inglês (english version)
Conteúdo (article):
Integrative review of the literature on hospitalizations of older people for ambulatory care-sensitive conditions in Brazil
Abstract
Hospitalisations for ambulatory care-sensitive conditions (HACSCs) – which are important in older adults, because of their greater vulnerability to chronic diseases and comorbidities – can be prevented by proper primary health care (PHC). Objective: an integrative review of articles on HACSCs in older adults and their correlation with indicators of access to primary care. The Virtual Health Library and PUBMED databases were searched. Inclusion criteria were articles addressing a relationship between HACSCs and primary care, published from 2000 to 2022, analysing the older adult age group, using statistical methods, in Portuguese, Spanish or English and indexed in peer-reviewed journals. Duplicate articles and those failing to meet the criteria were excluded. Of the 315 publications identified, 15 were selected, 12 of which focused on older adults. Brazil’s South and Southeast regions were the most studied and the year with most publications was 2012. The indicator most commonly used was coverage by the Family Health Strategy. The method most used for correlation was Pearson. Lower HACSC rates among older adults correlated positively with PHC access. Monitoring of HACSCs is an important tool for managing older adult health, and primary care is strategic to reducing hospitalisations, minimising risks and promoting healthy ageing.
Keyword: ambulatory care-sensitive conditions, hospitalisation, review, older adults, health status indicators.
INTRODUCTION
Hospitalisations for ambulatory care-sensitive conditions (HACSCs) are those that could be prevented or treated early with appropriate primary health care (PHC)1. HACSCs are important as indicators of PHC quality, because they reflect the efficacy of prevention and early treatment of people’s health problems1,2. In that regard, efficient, effective PHC contributes to reducing HACSCs3.
This topic is widely discussed by the scientific community, both in Brazil and worldwide5. Evidence shows that the older adult population suffers more from ACSCs6,7, such as heart failure, pneumonia, respiratory failures and diabetes8–11.
One strategy fundamental to the prevention and early treatment of health conditions in older adults is to strengthen PHC, thus averting unnecessary hospitalisations and promoting health and wellbeing in this population12,13. Immunosenescence, the process of declining ability to respond to infections, increased contamination, severity of infectious and contagious diseases and complications from chronic diseases, places older adults at the centre of challenges for PHC: averting hospitalisations means reducing the risk of functional capacity loss and even death6.
Review studies of knowledge production on HACSCs in Brazil have centred mostly on children14,15, while studies of older adults are scarce16,17. Given increasing rates of population ageing, growing demand from older adults for PHC services and the importance of systematising knowledge in this field in order to inform public policies, this article reports on an integrative review of the literature published from 2000 to 2022 on HACSCs of older adults and the correlation with indicators of PHC service access.
METHODOLOGY
The integrative review method was selected, as it enables the knowledge produced on a given issue to be compiled by identifying, analysing and synthesising the results of a survey of related research (Souza et al., 2010). In order to ensure transparency and quality, the review was guided by the criteria set out in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The PRISMA principles were obeyed, and flow diagram used to frame the identification, analysis, eligibility and inclusion of articles.
This study was guided by the question: “What is the correlation, in Brazil, between ACSCs and indicators of service access?”
What is the scientific evidence of the impact of PHC on HACSCs of older adults in the territory in the period from 2000 to 2022? With a view to answering that question, the analysis addressed PHC indicator types, information sources, specificity of the analysis of older adults, geographical scope, main causes, HACSC rates among older adults, methods applied to correlate HACSCs with PHC service access indicators, as well as evidence of that correlation.
The bibliographic survey was conducted in the following data bases: Virtual Health Library (VHL) and Medical Literature Analysis and Retrieval System Online (PUBMED/MedLine). The study period, from 2000 to 2022, made it possible to observe trends and impacts resulting from implementation of SAS/MS Order No. 221, of 2008. The article search used the Health Science Descriptors (DeCs) “condições sensíveis” OR “condição sensível” on the VHL platform and the Medical Subject Headings (MeSH) “sensitive conditions” OR “sensitive condition” on the PubMed base. An additional search of Google Scholar expanded the scope of the literature review using the same DeCS descriptors as above.
Articles were selected on the following inclusion criteria: a. studies of HACSCs of older adults; b. using some statistical method to relate HACSCs to PHC indicators; c. in Portuguese, Spanish or English; and d. indexed in a peer-reviewed journal.
The exclusion criteria were: a) not relating HACSCs to PHC indicators; b) not falling within the study period; (c) theses or dissertations; d) not available in complete form; or e) not studies of older adult populations.
Data extraction
Data were extracted from the articles included in the review by way of three predefined extraction tables. The first was developed and provided to the reviewers for analysing the articles against the inclusion criteria for the purpose of assessing each article for eligibility. It consisted of five columns: (a) article/author, (b) publication type, (c) geographical scope, (d) age range studied and (e) data base. The second was used to appraise the selected articles by recording the presence or absence of analysis of correlations between HACSCs and PHC access indicators, as well as the main evidence found. The third extraction table, designed to summarise the review findings, comprised five columns: (a) category of HACSC, (b) PHC indicators used in the correlation, (c) source, (d) correlation method and (e) correlations found. All research results were stored on Excel spreadsheets.
Review procedure
In order to ensure a complete assessment, three reviewers first examined all article titles and abstracts against the pre-established eligibility criteria. The reviewers underwent detailed training, emphasising the effective use of extraction tables and giving clear guidance on the inclusion criteria and the specific categories in each column.
At the first stage, two researchers separately examined each article and recorded their conclusions on a table contemplating the title, abstract and content. In the event an article met all the inclusion criteria, it advanced to the next stage, where the complete text was reviewed against the criteria detailed in Table 1. At the second stage, two researchers reviewed in full all the articles included, applying the inclusion and exclusion criteria. Disagreements during screening were resolved by discussion and, if necessary, a third researcher acted as judge.
RESULTS
The PRISMA flow diagram (Figure 1) shows the process by which articles were selected for analysis in this review. First, the data base search identified 315 publications (275 in the Virtual Health Library and 40 in the PubMed/MedLine data base).
Of these, 93 were duplicates and one was unavailable in the data bases; these 94 publications were excluded. At the next stage, 221 publications were examined in full; 209 of them were excluded on the study inclusion and exclusion criteria. A further three were added after a complementary search of Google Scholar. In all, 15 articles were included in this integrative review.
Figure 1: PRISMA flow diagram of article selection:
On examining for geographical scope, it was found that most of the studies considered all of territorial Brazil (6) (Graph 1). By administrative regions of Brazil, most studies correlating HACSCs of older adults with PHC access indicators were concentrated in the Southeast (5), followed by the South (2). Only one article addressed the North and one, the Northeast.
Graph 1. Regions of Brazil addressed by the articles in this review, Brazil 2000-2022.
Table 1. Integrative review of articles on hospitalisations of older adults for ambulatory care-sensitive conditions (HACSCs), 2000 to 2022, Brazil.
The integrative review identified articles addressing study periods between 1998 and 2019; of these, 2012 was the year most frequently contemplated (9) (Table 1).
The predominant study design was ecological (13), with variations including descriptive, time series, spatial analysis and retrospective studies. One study made an exploratory time series analysis and another, a cross-sectional analysis (Table 1).
The older adult population group was analysed exclusively in 40% (6) of the articles selected6,8,10,18,19 (Table 1).
The results revealed a higher prevalence of hospitalisations among individuals over 60 years of age; around 59.3% of hospitalisations in all regions. HACSC rates declined significantly over the study period (Table 1).
Municipalities where per capita income was higher correlated with lower HACSC rates6,20. Greater coverage by the family health strategy (Estratégia de Saúde da Família, ESF) was also associated with lower HACSC rates in the older adult population8,21–24. A study in Paraná attributed the decrease in HACSC rates between 2000 and 2012 to socioeconomic improvements19. Socioeconomic indicators such as urbanisation, illiteracy and national health system (Sistema Único de Saúde, SUS) beds correlated positively with HACSC rates (Table 1).
Table 2. Results of correlations between PHC service access indicators and HACSCs, Brazil, 2000-2022.
Most of the articles (13) used the complete list of causes as their indicator of HACSCs. Two studies each concentrated on analysing a specific cause of HACSCs: heart failure25 and arterial hypertension26 (Table 2).
An analysis of the sources revealed a variation over the study period. More recent studies used more current sources, such as Brazil’s primary care information system (Sistema de Informação da Atenção Básica, SIAB) and national register of healthcare establishments (Cadastro Nacional de Estabelecimentos de Saúde, CNES) from 2014 onwards. The sources most used were the SIAB, in 10 articles, followed by the primary care department (Departamento de Atenção Básica, DAB), in 5 studies, and the CNES, in 4 (Table 2).
Different statistical methods were used to examine the correlation between HACSCs and PHC access indicators. Pearson correlation, the commonest technique, was used in six studies, followed by multivariate regression analysis, in two, and Spearman correlation, in two (Table 2).
The findings showed significant evidence that ESF coverage and the number of healthcare appointments for older adults related negatively with HACSC rates. On the other hand, the number of hospital beds showed a positive relation, with each additional bed per 1,000 population resulting in an increase in HACSCs. However, increased ESF coverage had the opposite effect, leading to a reduction in HACSCs (Table 2).
The analysis also identified significant correlations between HACSCs and socioeconomic factors, such as Gini index, per capita income and municipal human development index (MHDI) (Table 2).
DISCUSSION
The articles examined found that older adults account for most HACSCs in Brazil. The natural process of ageing leaves people more vulnerable to comorbidities, which increases demand for health services. Population ageing in Brazil in recent decades has had an impact on the profile of morbidity and mortality, particularly as the result of a considerable increase in chronic noncommunicable diseases (NCDs), which are the leading cause of HACSCs of older adults18,27,28.
Most of the articles found a correlation between ESF coverage and HACSC rate: greater ESF coverage was associated with lower HACSC rates, suggesting that the presence of multidisciplinary PHC teams and promotion and prevention measures can contribute to improving care and to controlling health conditions, thus averting preventable hospitalisations6,22,25,29.
The studies indicated that lack of access to quality hospital services can increase demand for hospitalisations. Pazó et al.22 argued that the positive correlation between HACSC rate and the number of SUS beds can be explained by the absence of appropriate PHC service structure, leading to hospital system overload. Meanwhile, Silva6 found that the increase in ESF coverage resulted in a significant reduction in HACSC rates, suggesting that this model of primary care is effective in preventing avoidable hospitalisations. These results point to the importance of public policies to expand and upgrade primary health care services, with a view to reducing the demand for hospital services and improving the quality of care.
High HACSC rates are related to a number of factors, including the functioning of the hospital system, access to emergency services, hospital admission practices and medical criteria for hospitalisation22. Moreover, the profile of hospital morbidity among older adults was found to be changing: heart failure was less frequent, while pneumonia was occurring increasingly, to become the main cause of HACSCs in 20188,11,18,25.
In order to develop fairer, more equitable health policies, it is crucial to understand the incidence of HACSCs among ethnic and racial groups. The prevalence of HACSCs is higher among the population of older black adults than in other ethnic and racial groups, which may be attributable to historical, structural social inequalities and this population’s greater social vulnerability30. However, it is important to note the lack of quality in data on race and colour in the SUS health information system (SIH-SUS), which makes it difficult to obtain precise information and to assess health service performance from the perspective of race or ethnicity31.
Although a downward trend has been found in HACSCs in both sexes, a disparity persists: males are more liable to HACSCs than females18. This may be explained by the higher number of comorbidities presented by men over their life course, as well as by their resorting less to health services than women, as found in previous studies32.
Two articles included in this review examined per capita income. Although this study has not focused on this socioeconomic indicator, it has significant impact in higher HACSC rates, in that it hinders access to health services in Brazil10,15,21,22,26,33. People with little purchasing power do not often tend to use health services to prevent diseases, but rather to treat them39, which may result in more hospitalisations10,33. That situation underlines the importance of access to effective PHC services8,15,29,33, especially in the context of social and health inequality that persists in Brazil34.
Analysis of the studies revealed a significant disparity among studies in the South and Southeast regions as compared with those in other regions of the country. That fact may be related to the quality of health information in regions outside the South and Southeast. Not only are health services and resources unequal among regions, but so is knowledge production to permit evidence-based interventions to reduce health inequalities in Brazil35.
The findings of this study provide evidence that HACSC rates are influenced by a multiplicity of factors that affect primarily the older adult population. It is essential to strengthen and invest in PHC in order to reduce HACSC rates in this age group. For that purpose, PHC services need to be continuous and upgraded10,25,29. Investment in primary health care measures and programmes can assure healthy ageing to the population by preventing chronic diseases and unnecessary hospitalisations. In addition, HACSCs are an important indicator for public health management to identify areas requiring intervention to improve people’s quality of life2.
STUDY LIMITATIONS
It is important to note the limitations of this study. Firstly, articles were selected on pre-established criteria and, accordingly, important articles that fail to meet the criteria may have been excluded. Also, quality variations among the studies included in the review may have affected the results. Note also that the review did not include studies not published in scientific journals, such as technical reports and doctoral dissertations, which may have disregarded important information. Another limitation is that the review considered only the SIH-SUS data base and, as a result, hospitalisations in private facilities were not contemplated.
Lastly, it is important to mention that this review was based on studies available during the study period, meaning that studies published after that period may have brought out important additional evidence.
CONCLUSION
In conclusion, this review permitted more in-depth analysis of the incidence of HACSCs in older adults in Brazil, together with the associated social factors, such as socioeconomic conditions, sex and race. Health policies directed to reducing HACSCs in more vulnerable social groups are needed in order to guarantee better quality of life and the right to healthy ageing for everyone.
This study found high prevalence of HACSCs among older adults, caused primarily by morbidity and mortality from cardiovascular diseases. In addition to quality PHC services, health education directed to self-care may constitute an important strategy for reducing HACSCs.
From the health management standpoint, continuous, timely monitoring of HACSC rates is a sentinel indicator fundamental to assessing the quality of primary care offered to older adults in Brazil, because it can be used to identify areas of fragility in the health system.
Given the high prevalence of HACSCs in older adults in Brazil, this study highlights the importance of primary health care as a crucial tool in preventing and controlling ACSCs. Government must strengthen and prioritise PHC, because it is the main means of guaranteeing access to health care and, as a result, to maintaining quality of life for the user population. Accordingly, there is a need to invest in public policies that promote health service access and quality, with special attention to the population of older adults and underserved regions, so as to reduce the inequalities and help maintain quality of life.
Future studies, which should be both qualitative and quantitative, are needed to pursue this discussion in greater depth and produce evidence on regional disparities and sociodemographic inequalities in HACSCs.
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