Structure and work process in primary care and hospitalizations for sensitive conditions

ABSTRACT OBJECTIVE The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions. METHODS In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (β) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%). RESULTS In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (β = -0.001) and private insurance (β = -0.01) had a negative association, and the human development index (β = 1.13), the proportion of older adults (β = 0.05) and children under the age of five (β = 0.05), and the coverage of the Community Health Agent Strategy (β = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (β = -0.14) and availability of vaccines (β = -0.16) showed a negative association, and availability of medications showed a positive association (β = 0.16). In the proximal level, only the variable of matrix support (β = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013. CONCLUSIONS The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities.摘要 研究目的：本研究旨在探究基层卫生机构（primary health units）结构特征与基层医疗团队（primary care teams）工作流程，是否与基层医疗敏感病症（primary care sensitive conditions）的住院人次存在关联。 研究方法：本研究为生态学研究，分析了巴西各市政辖区的相关数据，涵盖社会人口学特征、医疗保障计划覆盖情况、基层卫生机构结构及基层医疗团队工作流程。数据来源于巴西统一卫生系统信息技术部的巴西基层医疗可及性与质量提升计划首轮数据集、巴西地理与统计研究所，以及联合国开发计划署（United Nations Development Programme）。关联分析采用负二项回归系数（β）及对应95%置信区间，并采用三层分级分析方法（检验水准α=5%）。 研究结果：针对2013年结局指标的校正分析显示，在远端层面，家庭补助金计划（Bolsa Família Program）覆盖比例（β=-0.001）与私人医保覆盖率（β=-0.01）与基层医疗敏感病症住院人次呈负相关；人类发展指数（β=1.13）、老年人口占比（β=0.05）、5岁以下儿童占比（β=0.05）以及社区健康工作者策略（Community Health Agent Strategy）覆盖比例（β=0.002）与住院人次呈正相关。在中间层面，最低工作时长要求（β=-0.14）与疫苗供应可及性（β=-0.16）呈负相关，而药物供应可及性则呈正相关（β=0.16）。在近端层面，仅矩阵支撑（matrix support）变量呈正相关（β=0.10）。针对2014年基层医疗敏感病症住院人次的校正分析中，各变量的关联方向与2013年一致。 研究结论：基层卫生机构结构特征与基层医疗团队工作流程，会对巴西各市政辖区的基层医疗敏感病症住院人次产生影响。