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Internamentos por Causas Sensíveis aos Cuidados de Saúde Primários em Portugal Continental: uma análise pela severidade
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RESUMO - Introdução: Para a avaliação do desempenho dos Cuidados de Saúde Primários
pode recorrer-se à análise dos Internamentos por Causas Sensíveis aos Cuidados
de Saúde Primários (ICSCSP). Estes correspondem a condições clínicas em que a
prestação de cuidados atempados e efetivos pelos CSP poderia evitar a admissão
hospitalar. Este indicador tem sido amplamente utilizado em diferentes países. Não
obstante, o seu ajustamento pelas características dos indivíduos internados (como a
severidade) representa uma linha de investigação pouco explorada. Assim, este
estudo tem como objetivos gerais: caracterizar a severidade dos ICSCSP em
Portugal e analisar o impacto desta variável nos ICSCSP.
Metodologia: Desenvolveu-se um estudo observacional, transversal e analítico,
recorrendo a dados retrospetivos relativos aos internamentos nos hospitais públicos
do SNS em Portugal Continental, no biénio 2013-2014 (n = 1 956 249). Foram
considerados internamentos evitáveis aqueles definidos por Caminal et al. (2004).
Para atribuição da severidade utilizou-se o sistema de classificação de doentes
APR-DRG, versão 31. Utilizou-se estatística descritiva para caracterizar a
severidade dos ICSCSP e modelos de regressão logística múltipla para analisar a
influência da severidade na ocorrência de ICSCSP.
Resultados: Para o biénio analisado, os ICSCSP representaram 16,4% do total de
internamentos e 20,1% dos internamentos por causas médicas. Pela caracterização
dos ICSCSP, observou-se que 26,3% destes internamentos apresentaram
severidade alta. Este valor é mais do que 3 vezes superior ao verificado nos
internamentos não-ICSCSP (7.1%). A DPOC, insuficiência cardíaca e pneumonia
apresentaram a maior proporção de casos de severidade alta (superior a 35%). As
regiões do Centro, Lisboa e Vale do Tejo e Entre o Douro e Minho registaram
maiores taxas de ICSCSP de severidade alta. Pela análise dos modelos aferiu-se
que a severidade está associada a um aumento da probabilidade de ocorrência de
ICSCSP, sendo que a insuficiência cardíaca, pneumonia e DPOC foram as causas
que apresentaram maior associação com esta variável. Observou-se também uma
forte associação entre a idade e a severidade dos episódios de internamento.
Conclusões: Os ICSCSP em Portugal têm maior severidade do que os
internamentos não-ICSCSP. A severidade é particularmente mais elevada nos
internamentos por insuficiência cardíaca, pneumonia e DPOC. Existem assimetrias
regionais na distribuição da severidade dos ICSCSP. Determinou-se ainda que o
aumento da severidade aumenta a probabilidade de ocorrência dos ICSCSP.
Considera-se o ajustamento pela severidade uma ferramenta útil na utilização futura
dos ICSCSP enquanto indicador. Não obstante, a forte relação entre a idade a
severidade recomenda precaução na utilização deste sistema de classificação
enquanto proxy da severidade dos internamentos.
ABSTRACT - Introduction: The analysis of the admissions for Ambulatory Care Sensitive Conditions (ACSC) can be applied for Primary Health Care (PHC) performance measurement. This indicator represents conditions for which timely and effective PHC could avoid hospital admission and it's been widely used in different countries. However, its adjustment by inpatients' characteristics (for example, the severity) presents lack of scientific evidence. Therefore, the main aims of this study are: characterize the severity of the admissions for ACSC in Portugal and analyse the impact of this variable in this indicator. Methods: It has been developed an observational, cross-sectional and analytical study, using retrospective data from inpatient episodes occurred in the portuguese public National Health Services' hospitals for 2013-2014 (n = 1 956 249). ACSC were considered those defined by Caminal et al. (2004). For the severity assignment it was used the patient classification system APR-DRG, version 31. Descriptive statistics was made to characterize the severity of the admissions for ACSC and multiple logistic regression models were developed to analyse the impact of the severity in this indicator. Results: For the years analysed, the admissions for ACSC represented 16,4% of all inpatient episodes and 20,1% of all the admissions by medical cause. By describing the admissions for ACSC, 26,3% of this episodes presented high severity. This value was 3 times more than the verified for all the other admissions, the non-ACSC (7,1%). Among the 10 most frequents causes of ACSC, COPD, heart failure and pneumonia showed the biggest proportion of high severity episodes (more than 35%). The regions of Centro, Lisboa e Vale do Tejo and Entre o Douro e Minho registered the greatest rates of high severity admissions for ACSC. The regression models showed that the severity is associated with an increased likelihood of admission for ACSC, representing the heart failure, pneumonia and COPD the causes that presented the biggest association with this variable. It was also obtained that age is strongly associated with the inpatient episodes' severity. Conclusions: The admissions for ACSC have greater severity than the episodes for non-ACSC. Severity is particularly higher for the admissions by CPOD, heart failure and pneumonia. There are regional variations in the ACSC admissions' severity distribution. Severity increase raises the likelihood of admission for ACSC. Severity adjustment it's considered as a useful tool to apply in the indicator of ACSC admissions. Nevertheless, the strong relation between age and severity recommends precaution in using this classification system as proxy for the inpatient episodes' severity.
ABSTRACT - Introduction: The analysis of the admissions for Ambulatory Care Sensitive Conditions (ACSC) can be applied for Primary Health Care (PHC) performance measurement. This indicator represents conditions for which timely and effective PHC could avoid hospital admission and it's been widely used in different countries. However, its adjustment by inpatients' characteristics (for example, the severity) presents lack of scientific evidence. Therefore, the main aims of this study are: characterize the severity of the admissions for ACSC in Portugal and analyse the impact of this variable in this indicator. Methods: It has been developed an observational, cross-sectional and analytical study, using retrospective data from inpatient episodes occurred in the portuguese public National Health Services' hospitals for 2013-2014 (n = 1 956 249). ACSC were considered those defined by Caminal et al. (2004). For the severity assignment it was used the patient classification system APR-DRG, version 31. Descriptive statistics was made to characterize the severity of the admissions for ACSC and multiple logistic regression models were developed to analyse the impact of the severity in this indicator. Results: For the years analysed, the admissions for ACSC represented 16,4% of all inpatient episodes and 20,1% of all the admissions by medical cause. By describing the admissions for ACSC, 26,3% of this episodes presented high severity. This value was 3 times more than the verified for all the other admissions, the non-ACSC (7,1%). Among the 10 most frequents causes of ACSC, COPD, heart failure and pneumonia showed the biggest proportion of high severity episodes (more than 35%). The regions of Centro, Lisboa e Vale do Tejo and Entre o Douro e Minho registered the greatest rates of high severity admissions for ACSC. The regression models showed that the severity is associated with an increased likelihood of admission for ACSC, representing the heart failure, pneumonia and COPD the causes that presented the biggest association with this variable. It was also obtained that age is strongly associated with the inpatient episodes' severity. Conclusions: The admissions for ACSC have greater severity than the episodes for non-ACSC. Severity is particularly higher for the admissions by CPOD, heart failure and pneumonia. There are regional variations in the ACSC admissions' severity distribution. Severity increase raises the likelihood of admission for ACSC. Severity adjustment it's considered as a useful tool to apply in the indicator of ACSC admissions. Nevertheless, the strong relation between age and severity recommends precaution in using this classification system as proxy for the inpatient episodes' severity.
Descrição
Palavras-chave
Internamentos por Causas Sensíveis aos Cuidados de Saúde Primários Internamentos Evitáveis Severidade Ambulatory Care Sensitive Conditions Avoidable admissions Severity