文章基本信息

标题：The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007
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作者：James Macinko ; Veneza B. de Oliveira ; Maria A. Turci 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2011
卷号：101
期号：10
页码：1963-1970
DOI：10.2105/AJPH.2010.198887
语种：English
出版社：American Public Health Association
摘要：Objectives. We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care–sensitive (ACS) hospitalizations among adults in Brazil. Methods. We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables. Results. The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds. Conclusions. These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil. Hospitalizations for ambulatory care–sensitive (ACS) conditions have been used to monitor health system performance in the United States and in several European countries.^{1 – 3} The idea behind the indicator is that hospitalizations for certain health problems represent a failure of the health system to provide access to good quality primary care, which should have detected the condition early in its progression, reduced its severity, or prevented the appearance of complications, thus obviating the need for hospitalization. Ambulatory care–sensitive hospitalization rates have been associated with primary care access and quality in several countries, including Australia, Canada, Spain, and the United States.^{4 – 9} However, these measures have rarely been used to study health system performance in low- and middle-income countries. Several reasons exist for seeking a tool to assess primary care effectiveness at this time in Brazil. These reasons include the ongoing process of developing the national health system, which has been taking place since 1988.¹⁰ In addition, since 1994 the country has rolled out the Family Health Program (FHP) as a new, robust model of community-based primary health care explicitly designed to provide accessible, first-contact, comprehensive, and whole-person care that is coordinated with other health and social services and takes place within the context of families and communities. Each FHP team is multiprofessional and contains at least 1 physician, 1 nurse, 1 medical assistant, and 4 to 6 community health agents. Teams are organized by geographic regions and with a specific territory containing approximately 3500 people per team. The program enrolls the local population and uses local health data to plan health services and prevention efforts.¹¹ All services and some medications are free of charge. By 2007, FHP access expanded in nearly every municipality and now reaches nearly 93 million people. Concomitant changes have occurred in the Brazilian hospital sector. The government pays for about 80% of all hospitalizations, which consume nearly 70% of all national health expenditures.¹² Hospital care in the national health system takes place in government-owned and operated facilities (about 36% of all hospitalizations), as well as in private (about 37%) and nonprofit (about 27%) hospitals that have been contracted by the federal government.¹³ Main reforms have included a decrease in the private or nonprofit to public sector hospital bed ratio, changes to the payment system, and introduction of new procedures covered by the national health system. Our objective was to assess factors associated with ACS hospitalization rates in Brazil. Our main hypothesis was that the rapid scale-up of the FHP over the past decade in Brazil should have resulted in improved capacity for primary care to resolve common population health problems. There is some evidence of the impact of the program on mortality—especially among children.^{14 , 15} FHP effects on adult morbidity should be reflected in a decrease in ACS hospitalization rates, a hypothesis for which there is preliminary evidence, at least for some conditions.¹⁶ However, to our knowledge, no previous studies have assessed the role of the FHP in relation to other factors related to ACS hospitalization rates in the country.