Hospitalizations of the Elderly due to Primary Care-Sensitive Conditions in the South-Central Region of the State of Paraná

Hospitalizations due to Primary Care-Sensitive Conditions (HPCSC) are caused by diseases whose care must be carried out at the first level of care and when not carried out lead to hospitalization, such as bacterial pneumonia, complications of diabetes mellitus, systemic arterial hypertension, asthma, among others. In order to analyze the main groups of diseases that cause HPCSC in elderly people in the South-Central region of the state of Paraná, a descriptive, exploratory, and ecological study of elderly people aged 60 to 74 years was carried out from 2008 to 2018 using the Hospital Information System of the Unified Health System (HIS/UHS), available on the website of the UHS Department of Informatics (DATASUS). In the analyzed period, there were 19,948 hospitalizations of elderly people aged 60 to 74 years due to PCSC. 10,007 (50.16%) cases were of men and 9,941 (49.84%) of women; the group of causes with the highest incidence of hospitalization were pulmonary diseases at 23.86%, followed by bacterial pneumonia at 20.47%, and heart failure at 12.59%; and these three groups accounted for more than 50% of all hospitalizations. The findings demonstrate a higher male incidence of HPCSC, with lung diseases, pneumonia, and heart failure being the main pathologies that affect the elderly population in the studied region. This reinforces the idea that promotion and prevention actions can help to reduce the number of hospitalizations and improved quality of life.


INTRODUCTION
In the 1990s in the United States of America (USA), considering the high rates of hospitalization for some diseases, the problems with and difficulties in accessing health services, and the low resolution of Primary Health Care (PHC) lead to the creation of a diagnosis list of Hospitalizations due to Primary Care-Sensitive Conditions (HPCSC) with the objective of evaluating the North American public system by aiming to monitor HPCSCs 1 .
Primary Health Care-Sensitive Conditions (PCSC) are diseases whose care must be carried out at the first level of care and when not carried out can lead to hospitalizations, such as bacterial pneumonias, complications of diabetes mellitus and systemic arterial hypertension, and asthma, among others 2 . In Brazil, in 2008, an Ordinance of the Health Care Secretariat of the Ministry of Health (SAS/MS 221) was launched with the aim of evaluating the nation's PHC using HPCSC indicators 3 .
The main categories of PCSC described in this ordinance are: diseases preventable by immunization; non-infectious gastritis and its complications; anemias; nutritional deficiencies; ear, nose and throat infections; bacterial pneumonias; asthma, lung diseases; systemic arterial hypertension; angina; heart failure, cerebrovascular diseases; diabetes mellitus; epilepsy; kidney and urinary tract infections; skin and subcutaneous tissue infections; inflammatory diseases of the female pelvic organs; gastrointestinal ulcers; and diseases related to prenatal care and childbirth 4 .
The neglect and high values of HPCSC represent a fragility and low resolution of PHC. Therefore, the identification of the most prevalent groups among populations allows for the restructuring of policies and programs, as well as the reformulation of actions directed at diseases for each specific region since the current Brazilian territory is vast, possesses a great cultural, demographic, and socioeconomic diversity 5 .
In 1991, the Family Health Program (FHP) began to be implemented in Brazil with the aim of increasing access and expanding prevention actions and health promotion. In 1994, the Ministry of Health then launched the FHP as the National Policy for Primary Care (NPPC) aiming to change the existing biomedical model. Later, from the 2000s onwards, it was renamed as Family Health Strategies (FHS) through ordinance 2488/GM to replace the traditional Primary Care (PC) model, by working in territories, performing household registration, situational diagnoses, actions addressed to health problems in an agreeable manner with the community where it operates, while seeking to care for individuals and families at the same time 6 .
Thus, PHC is based on being the first level of health care, the gateway to the health system. The population must have access to basic specialties, which are: Internal Medicine, Pediatrics, Obstetrics, and Gynecology 7 . It must also develop actions to resolve health problems, coordinating with other levels of complexity in the health system, thus, forming an integrated network of services 8 . Studies show that PHC is capable of solving about 80% of the population's health needs and problems 7 .
With the prospect of a large increase in the elderly population, investing in studies that can contribute to the organization of health services and assist in planning the necessary actions for effective and quality care. Therefore, knowing the profile of hospitalizations among the elderly population becomes important for planning and monitoring public policies and directing financial and human resources 9 .
The expansion of FHS coverage will facilitate the population's access to services at this level of care, and at the same time, the quality of the care received will contribute to the reduction of HPCSC 10 .
The objectives of this study were to analyze the main groups of causes of Hospitalizations due to Primary Care-Sensitive Conditions in elderly individuals aged 60 to 74 years old, and to identify the HPCSC variables according to sex, age group, residence, and cause group. In this study, data of HPCSC's of elderly people living in the 15 municipalities that belong to the 7th Health Region of PR, located in the South-Central region of the state, were analyzed.
Among The data were collected with the help of the Excel Program and are presented as tables and graphs. The analysis of the results is supported by national and international literature on the researched subject.

RESULTS
The results of this study show that in the South-Central Region of the State of Paraná there were 19,948 hospitalizations of elderly aged 60 to 74 years for PCSC in the period from 2008 to 2018, where 10,007 (50.16%) cases were men and 9,941 (49.84%) were women; as seen in figure 1.
In figure 2 demonstrates the annual total of HPCSCs over the period studied. There was a peak in 2009 of 2,032 hospitalizations and this index decreased in the subsequent 5 years. In 2014, the lowest number of HPCSCs was obtained, totaling 1,609, increasing again later in 2015 and maintaining high levels until 2018, but in smaller numbers, indicating a gradual decrease.
When looking at was the year with the highest incidence.
Analyzing the HPCSCs according to group of cause, table 2 shows that in the population studied, the groups of causes with the highest incidence were lung diseases 23.86%, followed by bacterial pneumonia at 20.47%, and heart failure at 12.59%. These 3 groups were responsible for about 56.89% of all hospitalizations of the elderly aged 60 to 74 years old in the study period.
As can be seen in

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Thinking about population aging is necessary. It is estimated that in 2020 Brazil will have approximately 13 million elderly people (12.4%) and in the year 2060 more than a third of the population will be made up of people aged 60 years or more (33.7%). This indicates that there will be a possible overload on the health system because the elderly population uses the services in a higher proportion than other age groups 3 .
In a study on the trend of hospitalizations and mortality of elderly people due to PCSC in Santa Catarina, 842,682 elderly hospitalizations were accounted for during the study period (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015) and 303,757 of them were due to PCSC. Of these, women were responsible for 51.4% of hospitalizations and men for 48.6% 3 . Diverging with the results herein, as in the studied region, men were responsible for 50.16% of hospitalizations and women for 49.84%, with a small variation.
In a study in the South-Central region of Brazil, in the age group of 60 years or more, circulatory system diseases are the most prevalent, with Heart Failure, Angina, and Cerebrovascular Diseases as the main groups of causes with the highest rates of HPCSC 11 . This does not corroborate the data from the South-Central region of the state of Paraná, as the data found in this region demonstrated a prevalence of HPCSC due to chronic obstructive pulmonary diseases, followed by bacterial pneumonia and heart failure. These 3 subgroups accounted for about 56.89% of all hospitalizations of elderly aged 60 to 74 years in the study period.
The practice of caring for the elderly requires a global, interdisciplinary, and multidimensional approach, taking into account the physical, psychological, and social factors that influence the health of an elderly person, as well as the environment in which they are inserted, aiming to detect and prevent injuries while preserving autonomy, independence, and encouraging self-care 12 .
Research focused on HPCSC in the state of Paraná in the years 2000 to 2011 focusing on four basic causes, Systemic Arterial Hypertension (SAH), Diabetes Mellitus (DM), Cerebrovascular Diseases (CbV), and Chronic Congestive Heart Failure (CHF), identified 5,219,427 hospitalizations throughout the state where 691,253 were of these researched pathologies, or rather, 13% of all hospitalizations 13 .
Hospitalizations due to PCSC do not assess the patient's clinical condition or the quality of the medical treatment that led to hospitalization, but the effectiveness of policies and actions taken to face such health problems 14 .
Analyzing the relationship between HPCSC and FHS coverage is important due to their direct relationship. A study conducted in the period from 2000 to 2007 found an increase in FHS coverage and a reduction in hospitalizations due to PCSC in the state of São Paulo. However, this did not happen uniformly, which raises the hypothesis that the PHC did not reach the necessary quality 15 .
Thus, investigations on HPCSC can contribute as a theoretical subsidy for the strengthening of the UHS, as well as present reflections that enable interdisciplinary actions to be implemented, aiming at the main morbidities and PCSCs that may lead to hospitalization. Moreover, they may provide managers and professionals in the studied municipalities with an alternative perspective for creating policies to improve PHC actions and implementing practices aimed at health promotion and disease prevention.

CONCLUSION
The findings of this study demonstrate that surveys aimed at HPCSC rates allow for the assessment of the strengths and weaknesses of the FHS teams, showing that promotion and prevention actions can help to reduce the number of hospitalizations and provide the elderly with a better quality of life.
Therefore, it is necessary to deepen research aimed at PCSC so that they can be used as a theoretical subsidy in the creation of policies that help municipalities to achieve a PHC of excellence, thus, providing the elderly population with a perspective of healthy aging.