Hospitalizations for Ambulatory Care-Sensitive Conditions in Brazil and Portugal : A Comparative Study

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 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