Hospitalizations for ambulatory care-sensitive conditions in Brazil and Portugal: a comparative study

ABSTRACT - Background: Ambulatory Care Sensitive Conditions (ACSC) are health conditions for which adequate management, treatment and interventions delivered in outpatient setting could avoid the need of hospital admission. Hospitalizations for ACSC have been used to assess access, quality, and performance of the Primary Health Care (PHC). Portugal and Brazil have carried out reforms in their PHC delivery system in the last years, with similar organizational characteristics and objectives. While inter-country comparison provides opportunities for cross-country learning, ACSC have limitations as an indicator for quality of care. The aim of this thesis was to analyze the dynamics of hospitalizations for Ambulatory Care Sensitive Conditions in Brazil and Portugal. Methods: Firstly, a literature review was conducted to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing hospitalizations for ACSC across countries. Secondly, hospitalizations for ACSC in Brazil and Portugal were compared in the dimensions of occurrence, rates, causes, sociodemographic characteristics, costs of hospitalizations and economic impact, geographic distribution and variations, and identification of spatial clusters. The data for this comparison was obtained from administrative databases of all hospitalizations in public hospital in each country for the year 2015. ACSC were classified according to the methodology by the Agency for Healthcare Research and Quality. Thirdly, a longitudinal analysis was carried out to investigate if expansion of PHC reform in Brazil and Portugal (using coverage of Family Health Units as proxy) was associated to hospitalizations for ACSC. This analysis was conducted for the period 2007 and 2016 using the same administrative databases, and possible associations analyzed using Spearman’s correlation analysis, Kruskal-Wallis tests, and linear regressions. Results: The inter-country comparison of hospitalizations for ACSC can suggest health policy implications and potential points of improvements to reduce these events; however there are factors in the dimension of methods, population and health system that need to be accounted for. Hospitalizations for ACSC accounted for around 7 and 10% of all hospitalizations in Brazil and Portugal in 2015, respectively. Both countries have similarities in standardized rates and which conditions were more common, and differences in crude rates and age distribution. Each hospitalization for ACSC had an estimated cost of US$PPP 1,919 and 4,278 in Brazil and Portugal, respectively. Both countries presented expressive geographic variations in rates of hospitalizations for ACSC. These indicate room of ix improvement and efficiency gains in Brazil and Portugal. Rates of hospitalizations for ACSC between 2007 and 2016 decreased in Brazil and increased in Portugal; although there were indications that expansion of PHC reform may be associated to reductions in ACSC hospitalizations, these results only applied for specific conditions and geographic areas within each country, and for some conditions results were discordant between the two countries. Conclusions: It is important to reduce ACSC hospitalizations given the impact these events represent for health systems and for society. The existing literature on inter-country comparison of hospitalizations for ACSC agree that strengthening PHC and promoting access provides opportunities to reduce these events. There was no robust evidence of the association between expansion of PHC reforms in Brazil and Portugal and reduction of hospitalizations for ACSC, indicating that the PHC reforms did not produce the same results neither within or between countries and not for all conditions. Findings indicate that focused actions can be more effective to reduce such events, with examples in both countries serving as valuable clues for the learning process and improvement.RESUMO - Enquadramento: Ambulatory Care Sensitive Conditions (ACSC) [Condições sensíveis ao cuidado em ambulatório] são condições de saúde para as quais o cuidado, tratamento e intervenção adequados realizados em contexto ambulatorial poderiam evitar a necessidade de internamento hospitalar. Os internamentos por ACSC têm sido utilizados para avaliar o acesso, a qualidade e o desempenho dos Cuidados de Saúde Primários (CSP). Portugal e o Brasil realizaram reformas em seus CSP nos últimos anos, com características e objetivos organizacionais semelhantes. Embora a comparação entre países ofereça oportunidades de aprendizagem entre países, as ACSC têm limitações como indicador de qualidade do cuidado. O objetivo desta tese foi analisar a dinâmica dos internamentos por ACSC no Brasil e em Portugal. Métodos: Em primeiro lugar, foi realizada uma revisão da literatura para identificar as dimensões conceituais, metodológicas, contextuais e políticas e os fatores que precisam ser considerados ao comparar os internamentos por ACSC entre países. Em segundo lugar, os internamentos por ACSC no Brasil e em Portugal foram comparados nas dimensões de ocorrência, taxas, causas, características sociodemográficas, custos de internamento e impacto econômico, distribuição e variações geográficas e identificação de clusters espaciais. Os dados para essa comparação foram obtidos em bancos de dados administrativos de todas os internamentos em hospitais públicos de cada país para o ano de 2015. ACSC foram classificadas de acordo com a metodologia da Agency for Healthcare Research and Quality. Em terceiro lugar, uma análise longitudinal foi realizada para investigar se a expansão da reforma dos CSP no Brasil e em Portugal (utilizando a cobertura de Unidades de Saúde da Família como proxy) estava associada aos internamentos por ACSC. Esta análise foi realizada para o período de 2007 e 2016 usando os mesmos bancos de dados administrativos e as possíveis associações analisadas usando a análise de correlação de Spearman, testes de Kruskal-Wallis e regressões lineares. Resultados: A comparação de internamentos por ACSC entre países pode sugerir implicações para as políticas de saúde e pontos de melhorias potenciais para reduzir esses eventos; no entanto, existem fatores na dimensão dos métodos, população e sistema de saúde que precisam ser considerados. Os internamentos por ACSC representaram cerca de 7 e 10Ambos os países têm semelhanças nas taxas padronizadas e quais condições eram mais comuns, e diferenças nas taxas brutas e distribuição por idade. Cada internamento por ACSC teve um custo estimado de US$ PPP 1.919 e 4.278 no Brasil e em Portugal, respectivamente. Ambos os países apresentaram variações geográficas expressivas nas taxas de internamentos por ACSC. Estes resultados indicam espaço para melhorias e ganhos de eficiência no Brasil e em Portugal. As taxas de internamentos por ACSC entre 2007 e 2016 diminuíram no Brasil e aumentaram em Portugal; embora houvesse indícios de que a expansão da reforma dos CSP possa estar associada a reduções nas internações por ACSC, esses resultados se aplicam apenas a condições e áreas geográficas específicas de cada país, e para algumas condições os resultados foram discordantes entre os dois países. A redução dos internamentos por ACSC é importante devido ao impacto que esses eventos representam para os sistemas de saúde e para a sociedade. A literatura existente sobre a comparação de internamentos por ACSC entre países concorda que o fortalecimento dos CSP e a promoção do acesso oferecem oportunidades para reduzir esses eventos. Não houve evidência robusta da associação entre a expansão das reformas dos CSP no Brasil e em Portugal e a redução dos internamentos por ACSC, indicando que as reformas dos CSP não produziram os mesmos resultados nem dentro ou entre os países e nem para todas as condições. Os resultados indicam que as ações focadas podem ser mais eficazes para reduzir tais eventos, com exemplos em ambos os países servindo como pistas valiosas para o processo de aprendizagem e melhoria

identifying and comparing critical areas through spatial analysis

BACKGROUND: Hospitalizations for ambulatory care sensitive conditions have been used to assess the performance of primary health care. Few studies have compared geographic variation in rates of avoidable hospitalizations and characteristics of high-risk areas within and between countries. The aim of this study was to identify and compare critical areas of avoidable hospitalizations in Brazil and Portugal, because these countries have reformed their primary health care systems in recent years and have similar organizational characteristics. METHODS: An ecological study on hospitalizations for ambulatory care sensitive conditions produced in Brazil and Portugal in 2015 was used. Geographic variation of rates were analyzed and compared at the municipal level. A spatial scan statistic was employed to identify clusters with higher risk of hospitalizations for acute and chronic conditions in each country separately. Socioeconomic and primary health care characteristics of critical areas were compared to non-critical areas. RESULTS: There were high variations in rates of avoidable hospitalizations within and between Brazil and Portugal, with higher variations found in Brazil. A more evident pattern of rates was found in Portugal. Rates and cluster distribution of acute and chronic conditions had significant agreement for both countries. The differences in primary health care and socioeconomic characteristics between areas identified as high risk clusters and non-clusters varied between category of conditions and between countries. CONCLUSION: Brazil and Portugal presented expressive regional differences with respect to rates of avoidable hospitalizations, indicating that there is room to improve by reducing such events in both countries. Different areas presented distinct interactions between primary health care, socioeconomic characteristics, and avoidable hospitalizations. Results indicate that the primary health care reforms, with similar organizational characteristics in different contexts, did not produce similar results either between or within countries. Possible actions to reduce these events should be defined at a local level.publishersversionpublishe

what conditions make inter-country comparisons possible?

Hospitalizations for ambulatory care sensitive conditions have been extensively used in health services research to assess access, quality and performance of primary health care. Inter-country comparisons can assist policy-makers in pursuing better health outcomes by contrasting policy design, implementation and evaluation. The objective of this study is to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing these types of hospitalizations across countries. A conceptual framework for inter-country comparisons was drawn based on a review of 18 studies with inter-country comparison of ambulatory care sensitive conditions hospitalizations. The dimensions include methodological choices; population's demographic, epidemiologic and socio-economic profiles and features of the health services and system. Main factors include access and quality of primary health care, availability of health workforce and health facilities, health interventions and inequalities. The proposed framework can assist in designing studies and interpreting findings of inter-country comparisons of ambulatory care sensitive conditions hospitalizations, accelerating learning and progress towards universal health coverage.publishersversionpublishe

Direct costs of COVID-19 inpatient admissions at a University Tertiary Care Centre

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trends during the first month of Covid-19 response

Introduction: Since December 2019, more than 925,000 cases of COVID-19 have been reported worldwide, 8,251 cases in Portugal by the end of March. Previous studies related to the SARS pandemic showed a decrease up to 80% in the emergency care episodes. Hence, the objective of this study is to analyze the use of emergency services during the first pandemic month, compared to historical records. Methods: Data from emergency episodes in mainland Portugal, from January 2014 to March 2020, were downloaded from the National Health Service (NHS) Transparency Portal and the NHS monitoring website. The evolution of emergency services from March to September 2020 was forecasted based on historical data from January 2014 to February 2020. Information for March 2020 was forecasted globally, by the Regional Health Administration (RHA) and Manchester Triage System (MTS). Results: Compared with forecasted values, there was a 48% reduction in the number of emergency episodes in March 2020. In the analysis by the RHA, Alentejo had the smallest decrease in the number of episodes; interestingly, Alentejo is also the area with fewer COVID-19 cases in mainland Portugal. In the analysis by the MTS, the episodes classified as yellow showed the highest reduction (50%). For episodes classified as urgent, there is a difference of about 144,000 episodes during March 2020. Discussion: The results of this preliminary study are aligned with the evidence produced for previous pandemics. Data about the use of emergency services, demographic and clinical characteristics of the episodes would be relevant to analyze this reduction. Conclusion: There was a significant drop in the number of emergency service use in March 2020, and although the causes of this reduction are not determined, the association between the beginning of the pandemic and the reduction of demand is evident. Understanding this phenomenon is crucial to plan interventions to avoid unnecessary morbidities or deaths, caused by a delayed visit to the emergency department.publishe

Direct and lost productivity costs associated with avoidable hospital admissions.

BACKGROUND: Hospitalizations for ambulatory care sensitive conditions are commonly used to evaluate primary health care performance, as the hospital admission could be avoided if care was timely and adequate. Previous evidence indicates that avoidable hospitalizations carry a substantial direct financial burden in some countries. However, no attention has been given to the economic burden on society they represent. The aim of this study is to estimate the direct and lost productivity costs of avoidable hospital admissions in Portugal. METHODS: Hospitalizations occurring in Portugal in 2015 were analyzed. Avoidable hospitalizations were defined and their associated costs and years of potential life lost were calculated. Direct costs were obtained using official hospitalization prices. For lost productivity, there were estimated costs for absenteeism and premature death. Costs were analyzed by components, by conditions and by variations on estimation parameters. RESULTS: The total estimated cost associated with avoidable hospital admissions was €250 million (€2515 per hospitalization), corresponding to 6% of the total budget of public hospitals in Portugal. These hospitalizations led to 109,641 years of potential life lost. Bacterial pneumonia, congestive heart failure and urinary tract infection accounted for 77% of the overall costs. Nearly 82% of avoidable hospitalizations were in patients aged 65 years or older, therefore did not account for the lost productivity costs. Nearly 84% of the total cost comes from the direct cost of the hospitalization. Lost productivity costs are estimated to be around €40 million. CONCLUSION: The age distribution of avoidable hospitalizations had a significant effect on costs components. Not only did hospital admissions have a substantial direct economic impact, they also imposed a considerable economic burden on society. Substantial financial resources could potentially be saved if the country reduced avoidable hospitalizations

the case of Brazil and Portugal

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A percepção dos sentidos e significados no processo de aprendizagem de Ciências da Natureza nos anos iniciais do Ensino Fundamental

O presente trabalho visa relatar a análise prévia obtida através da observação da percepção e significados atribuídos pelos alunos durante a realização de atividades experimentais desenvolvidas na Oficina de Ciências “Fazendo Arte e Aprendendo Ciências”. A oficina foi realizada no laboratório de Ciências do Colégio de Aplicação (CAp) da Universidade Federal do Rio Grande do Sul (UFRGS) com alunos e alunas dos anos iniciais do Ensino Fundamental (2º ao 5º ano). A Oficina teve a orientação da professora regente e a participação de duas alunas do Programa Institucional de Iniciação à Docência (PIBID). O objetivo da oficina foi ensinar Ciências da Natureza de forma lúdica com o auxílio da arte buscando motivar o interesse por essa área do conhecimento, e aos poucos, conduzir as crianças, à utilização da linguagem científica. O trabalho realizado com as crianças seguiu as normas de segurança de trabalho em laboratório

Internamentos hospitalares durante a primeira vaga de COVID-19 em Portugal

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Wild dogs at stake: deforestation threatens the only Amazon endemic canid, the short-eared dog (Atelocynus microtis)

The persistent high deforestation rate and fragmentation of the Amazon forests are the main threats to their biodiversity. To anticipate and mitigate these threats, it is important to understand and predict how species respond to the rapidly changing landscape. The short-eared dog Atelocynus microtis is the only Amazon-endemic canid and one of the most understudied wild dogs worldwide. We investigated short-eared dog habitat associations on two spatial scales. First, we used the largest record database ever compiled for short-eared dogs in combination with species distribution models to map species habitat suitability, estimate its distribution range and predict shifts in species distribution in response to predicted deforestation across the entire Amazon (regional scale). Second, we used systematic camera trap surveys and occupancy models to investigate how forest cover and forest fragmentation affect the space use of this species in the Southern Brazilian Amazon (local scale). Species distribution models suggested that the short-eared dog potentially occurs over an extensive and continuous area, through most of the Amazon region south of the Amazon River. However, approximately 30% of the short-eared dog's current distribution is expected to be lost or suffer sharp declines in habitat suitability by 2027 (within three generations) due to forest loss. This proportion might reach 40% of the species distribution in unprotected areas and exceed 60% in some interfluves (i.e. portions of land separated by large rivers) of the Amazon basin. Our local-scale analysis indicated that the presence of forest positively affected short-eared dog space use, while the density of forest edges had a negative effect. Beyond shedding light on the ecology of the short-eared dog and refining its distribution range, our results stress that forest loss poses a serious threat to the conservation of the species in a short time frame. Hence, we propose a re-assessment of the short-eared dog's current IUCN Red List status (Near Threatened) based on findings presented here. Our study exemplifies how data can be integrated across sources and modelling procedures to improve our knowledge of relatively understudied species