The Bambuí Health and Aging Study (BHAS):
factors associated with hospitalization
of the elderly
Pro je to Bamb uí: fato re s asso c iad o s a inte rnaç õ e s
ho sp italare s e ntre id o so s na c o munid ad e
1 Escola Nacion al de Saú de Pú blica, Fu n d ação Osw ald o Cru z . Ru a Leop old o Bu lh ões 1480, Rio d e Jan eiro, RJ 21041-210, Brasil. 2 N ú cleo de Estu dos sobre Ep id em iologia e An trop ologia d o En velh ecim en to, Cen tro d e Pesqu isas Ren é Rach ou , Fu n d ação Osw ald o Cru z . Av. Au gu sto d e Lim a 1715, Belo Horiz on te, M G 30190-002, Brasil. 3 Laboratório de Ep id em iologia e An trop ologia M éd ica, Cen tro d e Pesqu isas Ren é Rach ou , Fu n d ação Osw ald o Cru z . Av. Au gu sto d e Lim a 1715, Belo Horiz on te, M G 30190-002, Brasil. 4 Departam en to de Psiqu iatria e N eu rologia, Facu ld ad e d e Med icin a, Un iversid ad e Fed eral d e M in as Gerais. Av. Alfred o Balen a 190, Belo Horiz on te, M G 30130-100, Brasil. 5 Departam en to de Medicin a Preven tiva e Social, Facu ld ad e d e Med icin a, Un iversid ad e Fed eral d e M in as Gerais. Av. Alfred o Balen a 190, Belo Horiz on te, M G 30130-100, Brasil.
Hen riqu e L. Gu erra 1,2,3 Josélia O. A. Firm o 1,2,3 Eliz abeth Uch oa 2,3,4
M aria Fern an d a F. Lim a-Costa 2,3,5
Abstract Th is stu d y aim ed to id en tify factors associated w ith h osp ital ad m ission s of th e eld erly. All resid en ts of Bam bu í, M in as Gerais State ≥60 years (n = 1,742) w ere selected . Som e 1,606 of th ese (92.2%) p articip ated in th e stu d y. Th e d ep en d en t variable w as th e n u m ber of h osp ital ad -m ission s (n on e, on e, an d t w o or -m ore) d u rin g t h e p rev iou s 12 -m on t h s. In d ep en d en t variables w ere grou p ed a s en a b lin g, p red isp osin g, a n d n eed - rela t ed fa ct ors. Th e st ron gest a ssocia t ion s w ith m u ltip le h osp ital ad m ission s w ere: livin g alon e; fin an cial con strain ts to p u rch ase of m ed -ica t ion ; a n d va riou s in d -ica t ors of n eed (w orse self-p erceived h ea lt h , m ore v isit s t o p h ysicia n , greater u se of p rescrip tion m ed ication s, an d h istory of coron ary h eart d isease). Su ch variables cou ld h elp id en tify old er ad u lts at greatest risk an d th u s p reven t h osp italization .
Key words Agin g; Health Services Accessibility; Hosp italization
Resumo O est u d o p rocu ra id en t ifica r fa t ores a ssocia d os com in t ern a çã o h osp it a la r en t re id osos. Fora m selecion a d os t od os os a d u lt os resid en t es em Ba m b u í, M in a s Gera is, com 60 ou m ais an os (n = 1.742). Deste total, 1.606 (92,2%) p articip aram n o estu d o. A variável d ep en d en te era o n ú m ero d e in tern ações h osp italares (0, 1 ou ≥2) n os ú ltim os 12 m eses. As variáveis in d e-p en d en tes foram classificad as com o facilitad oras, e-p red ise-p on en tes e relacion ad as a n ecessid ad es. As variáveis in d ep en d en tes qu e d em on straram associações m ais fortes com o n ú m ero d e in ter-n ações h osp italares foram : o fato d e viver soziter-n h o(a); restrições fiter-n ater-n ceiras à aqu isição d a m ed i-ca çã o p rescrit a e d iv ersos in d ii-ca d ores d e n ecessid a d e (p ercep çã o n ega t iv a d a p róp ria sa ú d e, n ú m ero m aior d e con su ltas m éd icas, m aior u so d e m ed icação com receita m éd ica e h istória d e d oen ça coron arian a). Estas variáveis p od eriam aju d ar a id en tificar os id osos com risco elevad o d e h osp italização e con tribu ir p ara m ed id as p reven tivas.
Introduction
Age in g o f th e p o p u la tio n wa s a p h e n o m e n o n in itia lly o b ser ved in d evelo p ed co u n tries, b u t in re ce n t ye a rs th e n u m b e r o f o ld e r a d u lts in d evelop in g n ation s h as in creased m ore rap id ly. Pro je ctio n s re ce n tly p u b lish e d b y th e Wo rld Hea lth Orga n iza tio n ( WH O) estim a te th a t b e-twe e n 1990 a n d 2,025 th e e ld e rly p o p u la tio n will in cre a se b y a p p roxim a te ly se ve n to e igh t tim es in cou n tries su ch as Colom b ia, Malaysia, Ken ya, Th ailan d an d Gh an a. Th e sam e p rojec-tion s in d icate th at five of th e 10 cou n tries with th e h igh est p o p u la tio n o f o ld er a d u lts in 2025 will b e d evelop in g cou n tries, in clu d in g Brazil, wh ere an estim ated n u m b er of 27 m illion p eo-p le will b e over 60 yea rs old ( WHO, 1998). Th e p rop ortion of p eop le a ged 60 or old er yea rs in Bra zil in cre a se d fro m 6.1% in 1980 (7,204,517 in h ab itan ts) to 7.9% in 1996 (12,398,678 in h ab -itan ts), corresp on d in g in ab solu te n u m b ers to a n in cre a se o f 5.2 m illio n in d ivid u a ls (IBGE, 1981, 1997).
Th e in crea se o f th e eld erly p o p u la tio n im -p lie s a gre a te r n u m b e r o f h e a lth -p ro b le m s, with th e h igh e st d e m a n d fo r h e a lth ca re se r-vices con cen tra ted with in th is grou p (Ka la ch e et al., 1987; Lim a-Costa et al., 2000a; Ram os et al., 1987; Taket, 1992; Veras et al., 1987). In Brazil, th e co sts o f h o sp ita l p u b lic a d m issio n s fo r in -d ivi-d u als age-d ≥60 years, wh o com p rised 7.9% o f th e p o p u la tio n o f th e co u n tr y in 1996, will rea ch 27.2% o f th e to ta l th is yea r (Lim a -Co sta et al., 2000a). It is kn own also th at th e h igh cost o f h e a lth se r vice s u tilize d b y th e o ld e r a d u lt p op u lation , p rin cip ally h osp ital ad m ission s, is con cen trated in a sm all su b grou p of th is p op u -la tio n (Fre e b o rn e t a l., 1990; McCa ll & Wa i, 1983; Ro o s & Sh a p iro, 1981; Ro o s e t a l., 1989; Zook & Moore, 1980). Mem b ers of th is m in ority co u ld h a ve a b e tte r h e a lth situ a tio n with le ss freq u en t h o sp ita l a d m issio n s, if th ey co u ld b e id en tified in ad van ce an d treated p reven tively (Bou lt et al., 1993). Th u s, kn owled ge of th e fac-tors associated with h osp ital adm ission s am on g th e eld erly is im p ortan t to p reven t th ese, or at least to organ ize th e p rovision of services at th e h o sp ita l, a m b u la to r y, co m m u n ity a n d h o u se-h old level (Bou lt et al., 1993, 1994; Evan s et al., 1988; Pacala et al., 1995), in ord er to p rod u ce a p o sitive im p a ct o n th e q u a lity o f life fo r o ld er ad u lts an d ration alize treatm en t costs.
Sin ce th e b e h a vio ra l m o d e l wa s p ro p o se d to in vestiga te th e d eterm in a n ts o f h ea lth service u tiliza tio n in th e ea rly 1970s (Ad a y & An -d ersen , 1974; An -d ersen & Newm an , 1973), vari-ou s stu d ies h ave b een carried vari-ou t in d evelop ed co u n trie s to id e n tify th e fa cto rs a sso cia te d
with u se of th e h ealth services by old er p eop le (Bran ch et al., 1981; Colem an et al., 1998; Evan s et al., 1988; Satish , 1996; Wolin sky et al., 1992). Mo re recen tly, p o p u la tio n -b a sed stu d ies h a ve been carried ou t in develop ed cou n tries to iden tify p re d ictive ch a ra cte ristics fo r h o sp ita l a d -m ission s in th is p op u lation (Bou lt et al., 1993; Hu rd & McGa rr y, 1997; Pa ca la e t a l., 1997). In gen eral, th ese h ave sh own th at th e m ost im p or-ta n t va ria b le s a re : p o o r se lf-p e rce ive d h e a lth sta tu s, m o re a d va n ced a ge, grea ter n u m b er o f visits to a d o cto r in th e p re vio u s ye a r, gre a te r n u m b e r o f m e d ica tio n s u tilize d , d isa b ility to p e rfo rm so m e a ctivitie s o f d a ily livin g (ADL) an d p resen ce of certain d iseases, su ch as coro-n a ry d isea se a coro-n d d ia b etes, a m o coro-n g o th ers. It is n ot kn own , h owever, if th ese variables are cap a-b le o f p re d ictin g h o sp ita l a d m issio n s a m o n g old er ad u lt resid en ts of d evelop in g cou n tries.
Th e fa cto rs a sso cia ted with th e u tiliza tio n o f h e a lth se r vice s (a m b u la to r y, h o sp ita l a n d o th e rs) in d e ve lo p in g co u n trie s we re in ve sti-ga te d b a se d o n cro ss se ctio n a l stu d ie s d e ve lop ed in Mexico (BorgesYáñ ez & Góm esDan -té s, 1998) a n d Bra zil (Pin h e iro & Tra va sso s, 1999). Th e form er stu d y, b ased on in form ation fro m a n a tio n a l h e a lth su r ve y ca rrie d o u t in 1994, verified th at m ore ad van ced age, in ab ili-ty to work d u rin g th e p reviou s week, access to social secu rity, an d rep ort of p reviou s d iagn o-sis of an y d isease were associated with u tiliza-tion of h ealth services. In th e latter stu d y, car-ried ou t in th e city of Rio d e Jan eiro, it was veri-fied th at th e factors associated with th e u tilizatio n o f h e a lth se r vice s b y th e e ld e rly we re fe -m a le se x, a cce ss to p riva te h e a lth p la n , re si-d en ce in rich est areas of th e city an si-d h istory of p rior d iagn osis of an y d isease.
To o u r kn owle d ge, n o stu d ie s h a ve b e e n d o n e in d evelo p in g co u n tries th a t sp ecifica lly exam in e ch aracteristics associated with h osp i-tal ad m ission s am on g old er ad u lts. Th e p resen t stu d y, u tilizin g d ata ob tain ed from th e b aselin e o f a Bra zilia n p ro sp e ctive stu d y o n h e a lth o f th e e ld e rly ( Th e Bam bu í Health an d Agin g Stu d y – BHAS)(Lim a -Costa et a l., 2000b ) a im s a t id e n tifyin g ch a ra cte ristics a sso cia te d with th e o ccu rren ce o f h o sp ita l a d m issio n s a m o n g old er ad u lts.
M aterial and methods
Study area
h u m an d evelop m en t in d ex in th e m u n icip ality d u rin g th a t ye a r wa s 0.70, life e xp e cta n cy a t b irth was 70.2 years an d 75% of d eath s occu rred a m o n g p e o p le ≥ 50 ye a rs o f a ge (FJP/ IPEA, 1996). Th e lead in g cau ses of d eath s in th e m u -n icip ality i-n 1996 were stroke (ICD-10: I60-I69), Ch agas d isease (ICD-10: B57), isch aem ic h eart d ise a se (ICD-10: I-20-I25), a n d p u lm o n a r y ch ro n ic o b stru ctive d isea se (ICD-10: J43, J44) (d e a th ra te s = 110.0, 61.4, 42.5 a n d 18.9 p e r 100,000, re sp e ctive ly) (DATASU S, 1998; OMS, 1995). Th e h igh m o rta lity ra te d u e to Ch a ga s’ d isease am on g th e resid en ts of th is com m u n ity is th e co n se q u e n ce o f p a st e xp o su re to in fe c-tio n with Tryp an osom a cru zi. Tra n sm issio n o f in fectio n h a s b een in terru p ted in th e m u n ici-p ality for over 20 years, h owever seroici-p ositivity rem ain s h igh am on g th e eld erly d u e to th e co-h ort effect (Lim a-Costa et al., in p ress).
Th e town o f Ba m b u í p o sse sse s a ge n e ra l h osp ital with 62 b ed s an d a p olyclin ic m u n ici-p a l th a t o ffe rs 24h r. Prim a r y He a lth Ca re. In 1996 th e re wa s o n e d o cto r p e r 1,000 in h a b itan ts of th e m u n icip ality. In th at year, 545 p u b -lic h o sp ita l a d m issio n s were registered u n d er th e p u b lic h e a lth syste m (Sistem a Ú n ico d e Saú de) for resid en ts of Bam b u í aged ≥60 years (DATASUS, 1997). Am o n g th ese, th e p rin cip a l cau ses were card iac in su fficien cy (CID-9: 428) an d b acterial p n eu m on ia (CID-9: 482, 485, 486) (a d m issio n ra te s = 28.9 a n d 25.2 p e r 1,000 in -h ab itan ts resp ectively) (OMS, 1985).
Study population
A com p lete cen su s of th e town of Ba m b u í wa s carried ou t by ou r research team in Novem b er an d Decem b er 1996 to id en tify th e p articip an ts o f th e stu d y. All th o se a ge d ≥60 ye a rs o ld o n Jan u ary 1st1997 were selected to p articip ate in th e b a se lin e o f th e co h o rt stu d y. Mo re d e ta ils can b e seen in Lim a-Costa et al. (2000b ).
Study variables
Th e d e p e n d e n t va ria b le o f th is stu d y wa s th e n u m b er of h osp ital ad m ission s d u rin g th e last 12 m o n th s (n o n e, o n e a n d two o r m o re). Ho s-p italization was d efin ed by s-p assin g at least on e n igh t in h osp ita l a s a p a tien t (Coron i-Hu n tley et al., 1986).
Selectio n o f in d ep en d en t va ria b les fo r th e p resen t stu d y followed th e m od el p rop osed by An d e rse n (Ad a y & An d e rse n , 1974; An d e rse n , 1995; An d e rse n & Ne wm a n , 1973) to in ve sti-gate ch aracteristics associated with h ealth service u se. Accord in g to th is m od el, th e in d ivid
-u a l d e te rm in a n ts o f th e -u tiliza tio n o f h e a lth services are grou p ed in to in d icators of p red is-p o sin g, e n a b lin g a n d n e e d . Th e va ria b le s o f p red isp osin g refer to ch aracteristics wh ose ex-isten ce p reced es th e occu rren ce of an y sp ecific ep isod e of d isease (gen d er, age an d b eliefs with re sp e ct to th e e ffica cy o f m e d ica l tre a tm e n ts a re exa m p les o f p red isp o sin g). En a b lin g va ri-ab les are factors th at m ake th e h ealth services availab le to th e in d ivid u al (in com e an d cover-in g for h ealth p lan s are exam p les of en ab lers). Va ria b le s o f n e e d re p re se n t m o re im m e d ia te ca u se s fo r th e u tiliza tio n o f h e a lth se r vice s (h isto r y o f p re vio u s d ia gn o sis o f a n y d ise a se a n d self-p erceived h ea lth sta tu s a re exa m p les of in d icators of n eed ).
Th e in d ica to r va ria b le s o f p re d isp o sin g in t h e p re se n t st u d y we re t h e fo llowin g: (1) a ge in ye a rs (60-69, 70-79, ≥80 ye a rs), (2) ge n d e r (m ale, fem ale), (3) m arital statu s (m arried / livin g to ge th e r, slivin gle, se p a ra te / d ivo rce d , wid -owed ), (4) ed u cation al level in com p leted years of sch oolin g (n on e, 1-3, 4-7, ≥8) an d (5) livin g alon e (yes or n o).
Data collection
Th e in form ation for th e p resen t stu d y was ob -tain ed th rou gh an in terview carried ou t in th e b a se lin e o f th e co h o rt stu d y, u sin g th e BH AS q u estion n aire. Th ese in terviews lasted ap p rox-im ately 90 m in u tes an d were carried ou t in th e h om es of th e in terviewees. Wh en th e in tervie-we e wa s u n a b le to re sp o n d to th e in te r vie w, d u e to a co gn itive d e ficit o r fo r so m e o th e r h e a lth re a so n , a n a p p ro p ria te p roxy re sp o n -d en t was u se-d (Magazin er, 1992; Nelson et al., 1990). Th e se p roxy d id n o t a n swe r q u e stio n s th at d ep en d ed on p erson al ju d gem en t, su ch as se lf-p e rce ive d h e a lth sta tu s. Mo re d e ta ils a re p rovid ed in Lim a-Costa et al. (2000b ).
Data analysis
Un ivariate an alysis was b ased on Pearson’s ch i-sq u are test an d ch i-i-sq u are test for lin ear tren d (Arm itage & Berry, 1987). Mu ltivariate an alysis was b ased on th e ad ju sted od d s ratios (OR) an d o n th e ir co n fid e n ce in te r va ls a t th e 95% le ve l o b ta in e d b y Wo o lf’s m e th o d (Sch le sse lm a n , 1982). Th e OR were a d ju sted b y logistic m u lti-n om ia l regressiolti-n (Ha m iltolti-n , 1993; Hosm er & Lam ersh ow, 1989), takin g as referen ce class th e a b se n ce o f h o sp ita l a d m issio n s in th e la st 12 m o n th s. Age a n d sex were co n sid ered a p riori
to b e p o te n tia l co n fo u n d in g va ria b le s in th is stu d y. All o th e r va ria b le s th a t a re in th e u n i-variate an alysis p resen ted association with th e n u m b er of h osp ital ad m ission s b elow th e 0.20 sign ifican ce level were exam in ed in th e m u lti-variate an alysis (Green lan d , 1989).
Mu ltiva ria te a n a lysis wa s ca rrie d o u t in tia lly b y e a ch o f th e th re e gro u p s o f d e te rm i-n ai-n ts (p red isp osii-n g, ei-n ab lii-n g or i-n eed ) follow-in g wh ic h t h e ffollow-in a l m o d e l wa s c o n st r u c t e d , in clu d in g a ll th e va ria b les th a t were a sso cia t-ed with th e n u m b er o f h o sp ita l a d m issio n s a t < 0.20 level in each grou p of d eterm in an ts.
Results
Of th e 1,742 eld erly selected , 1,606 (92,2%) p ar-ticip a ted in th e p resen t stu d y. Sixty p ercen t of th e p a rticip a n ts we re fe m a le a n d th e m e d ia n a ge wa s 68 ye a rs. Of th e se in d ivid u a ls, 1,244 (77.5%), 250 (15.6%) a n d 112 (7.0%) re p o rte d h avin g h ad n o, on e an d ≥2 h osp ital ad m ission s in th e last 12 m on th s, resp ectively.
Th e resu lts of th e u n ivariate an alysis of th e in d ica to rs o f p re d isp o sin g fo r h e a lth se r vice u tiliza tion , a ccord in g to th e n u m b er of h osp
i-tal ad m ission s are p resen ted in Tab le 1. All th e va ria b les stu d ied (gen d er, a ge, m a rita l sta tu s, livin g alon e, com p lete years of sch oolin g) were associated with th e n u m b er of h osp ital ad m is-sion s d u rin g th e last 12 m on th s.
Th e to ta ls o f th e u n iva ria te a n a lysis o f th e in d icators of en ab lin g for h ealth service u se are p re se n te d in Ta b le 2. Am o n g th e se va ria b le s, o n ly cove ra ge b y h e a lth p la n wa s n o t sign ifi-ca n tly a sso cia ted with th e n u m b er o f h o sp ita l a d m issio n s a t < 0.05 le ve l (p = 0.058). All th e oth ers (fam ily an d in d ivid u al in com e, rep ort of p ro b lem s o f a ccess to lo ca l m ed ica l a tten tio n a n d fin a n cia l p ro b le m s in o b ta in in g m e d ica tion ) were statistically associated with th e n u m -b er of ad m ission s.
Th e resu lts of th e u n ivariate an alysis of th e in d icators for n eed of u tilization of h ealth ser-vice s a re p re se n te d in Ta b le s 3 a n d 4, a n d a re b a se d o n th e n u m b e r o f h o sp ita l a d m issio n s. All of th ese p resen ted a sign ifican t association with th e n u m b er of h osp ital ad m ission s in th e la st 12 m o n th s (p < 0.05): n u m b e r o f visits to th e d o cto r d u rin g th e la st 12 m o n th s, n u m b er o f p re scrib e d m e d ica tio n s u se d in th e la st th ree m on th s, in a b ility to p erform rou tin e a c-tivities b ecau se of a h ealth p rob lem d u rin g th e last two weeks, h avin g b een b ed rid d en d u rin g th e last two weeks, in ab ility to walk 1.5km with -o u t tirin g, d isa b ility t-o ca rr y -o u t -o n e -o r m -o re d aily activities, p oor self-p erceived h ealth sta-tu s in th e last six m on th s, p ositive m ed ical h is-tory of coron ary d isease, arterial h yp erten sion , arth ritis, d iab etes an d Ch agas’ d isease.
Discussion
Th e ch a ra cte ristics m o st stro n gly a sso cia te d with th e o ccu rren ce o f h o sp ita l a d m issio n s in th e p resen t stu d y were th e in d ica to rs o f n eed . Th e m agn itu d e of th e association s was greater wh en two o r m o re h o sp ita liza tio n s were co n sid ered . Th is resu lt is co n sisten t with th a t o b -ser ved in two sectio n a l stu d ies (Bra n ch et a l., 1981; Hu rd & McGu rry, 1997) an d a p op u lation -b a se d p ro sp e ctive stu d y (Bo u lt e t a l., 1993) p erform ed in th e Un ited States. It is im p ortan t to em p h a size th a t th e in d ica to rs o f n eed were also th e on es m ost stron gly associated with u se of h ealth services in gen eral (am b u latory, h os-p ita l a n d o th e rs) in os-p re vio u s stu d ie s ca rrie d ou t in Mexico (Borges-Yáñ es & Góm es-Dan tés, 1998) an d Brazil (Travassos & Pin h eiro, 1999).
Am on g th e in d icator variab les of n eed , it is wo rth ca llin g a tte n tio n to th e se lf-p e rce ive d h e a lth sta tu s, wh ich in th e p re se n t stu d y wa s
stron gly associated with th e occu rren ce of two o r m o re h o sp ita liza tio n s. Th is in d ica to r h a s co n sisten tly b een fo u n d to b e a sso cia ted with th e o ccu rren ce o f h o sp ita l a d m issio n s a m o n g th e eld erly b oth in d evelop ed cou n tries (Bou lt et al., 1993; Bran ch et al., 1981) an d d evelop in g cou n tries (Fern án d ez-d e-la-Hoz & Leon , 1996). It is also im p ortan t to em p h asize th at p oor self-p erceived h ealth statu s h as b een a rob u st self-p re-d ictor of m ortality am on g olre-d p eop le in re-d iffer-en t cou n tries an d cu ltu res (Helm er et al.; 1999; Korten et al., 1999; Men ec et al., 1999; On awola et al., 1998).
Th e oth er in d icator variab les of n eed fou n d to b e in d ep en d en tly associated with th e occu r-re n ce o f h o sp ita liza tio n s in th e p r-re se n t stu d y (visits to a d octor, m ed ication s p rescrib ed , in ab ility to p erform activities d u e to h ealth p rob -lem s, b ed rid d en sta te a n d a n in a b ility to wa lk 1.5km with o u t tirin g), a re a lso in a gre e m e n t with th e fin d in gs o f stu d ie s ca rrie d o u t in d e
-Tab le 1
Distrib utio n o f ind ic ato rs o f p re d isp o sing fo r utilizatio n o f he alth se rvic e s, ac c o rd ing to the numb e r o f ho sp ital
ad missio ns d uring the last 12 mo nths amo ng o ld e r ad ults. Bamb uí, Minas Ge rais State , Brazil, 1997.
N umber of admissions
No ne O ne Two o r mo re p value * (n = 1,244) (n = 250) (n = 112)
% % %
Gender
Fe male 57,9 69,6 62,5
Male 42,1 30,4 37,5 0,002
Age (years)
60-69 59,4 55,6 49,1
70-79 30,8 30,0 29,5
> 80 9,8 14,4 21,4 0,002
M arital status
Marrie d / live to g e the r 51,0 38,8 47,3
Sing le 10,5 12,0 8,9
Divo rc e d / se p arate d 4,8 6,8 4,5
Wid o w 33,7 42,4 39,3 0,031
Living alone
Ye s 14,5 19,2 22,3
No 85,5 80,4 77,7 0,026
Years of schooling
No ne 30,3 38,4 44,6
1-3 33,4 28,4 33,9
4-7 27,7 25,6 19,6
> 8 8,5 7,2 1,8 0,003
velop ed cou n tries (Bou lt et al., 1993; Bran ch et al., 1981).
Th e u se of a greater n u m b er of m ed ication s p rescrib ed was in d ep en d en tly associated with o n e a n d two o r m o re h o sp ita liza tio n s in th e last 12 m on th s. Two h yp oth eses m ay b e raised to e xp la in th is fin d in g: first, th e n u m b e r o f m e d ica tio n s p re scrib e d m a y re fle ct a wo rse st a t e o f h e a lt h ; a n d t h e se co n d , t h e r isk m a y b e re la te d to th e co n co m ita n t u se o f d ive rse d ru gs, th is b e in g co m m o n a m o n g th e e ld e rly (Borges-Yáñ es & Góm es-Dan tés,1998; Mosegu i e t a l, 1999). A stu d y ca rrie d o u t in Swe d e n d e m o n stra te d th a t 25% o f h o sp ita liza tio n s were rela ted to a d verse effects o f m ed ica tio n s a n d th a t th e risk o f th e se re a ctio n s in cre a se d with th e n u m b er of d ru gs u sed (Cad igan et al., 1989). In Bra zil, th e q u a lity o f m ed ica tio n u se in eld erly p eop le wa s in vestiga ted by Mosegu i
et a l. (1999), wh o sh owed th a t th e o ccu rren ce of m ed ication in teraction an d oth er p rob lem s elevated th e risk of ad verse reaction s.
In a co h o rt stu d y ca rried o u t in th e Un ited Sta te s, it wa s sh own th a t th e m e d ica l h isto r y rep ort of coron ary d isease was associated with th e occu rren ce of h osp italization s. Oth er ch ron -ic d isea ses/ co n d itio n s su ch a s a rteria l h yp er-ten sion , d iab etes an d arth ritis d id n ot p resen t th is association (Bou lt et al., 1993). Sim ilar re-su lts were ob tain ed in th e p resen t stu d y.
Th e e xiste n ce o f a n a sso cia tio n b e twe e n d isab ility to p erform on e or m ore ADLs an d th e occu rren ce of h osp ital ad m ission was ob served in two cross section al stu d ies carried ou t in th e Un ite d Sta te s, (Bra n ch e t a l., 1981; Hu rd & McGu rr y, 1997), b u t th is a sso cia tio n wa s n o t fou n d in a coh ort stu d y p erform ed in th e sam e cou n try (Bou lt et al., 1993). In th e p resen t stu d y,
Tab le 2
Distrib utio n o f ind ic ato rs o f e nab ling fo r utilizatio n o f he alth se rvic e s, ac c o rd ing to the numb e r o f ho sp ital ad missio ns
d uring the last 12 mo nths amo ng o ld e r ad ults. Bamb uí, Minas Ge rais State , Brazil, 1997.
N umber of hospital admissions No ne O ne Two o r mo re p value ** (n = 1,244) (n = 250) (n = 112)
% % %
M onthly family income*
< 2,00 27,5 32,8 48,2
2,00 – 3,99 38,3 36,0 32,1
4,00 – 5,99 14,9 15,6 10,7
≥6 18,6 13,6 8,0 0,000
M onthly personnel income*
< 1,00 11,4 10,4 10,7
1,00 – 1,99 59,9 65,2 77,7
2,00 – 3,99 15,4 12,4 8,0
≥4,00 13,0 12,0 3,6 0,006
Private health plan
No 80,1 80,0 89,3
Ye s 19,9 20,0 10,7 0,058
M ajor problem to access medical services
No ne 36,2 28,8 20,5
Diffic ultie s o f ac c e ss to 8,3 16,8 20,5 me d ic al se rvic e s lo c al
O the rs 55,1 53,6 58,0 0,000
M ajor problem in obtaining medication
No ne 52,7 44,0 23,2
Financ ial p ro b le m 39,9 47,6 65,2
O the rs 7,2 7,6 10,7 0,000
th e association b etween d isab ility to carry ou t a t le a st o n e a m o n g five ADLs a n d th e o ccu r-re n ce o f h o sp ita l a d m issio n s e n co u n te r-re d in th e u n ivariate an alysis was n ot m ain tain ed af-ter ad ju stm en ts by con fou n d in g variab les.
With re sp e ct to th e in d ica to r va ria b le s o f p red isp osin g for h osp italization s, n on e was as-sociated with th e occu rren ce of a sin gle h osp i-ta l a d m issio n . Th e m a le se x a n d livin g a lo n e p re se n te d in d e p e n d e n t a sso cia tio n s with th e o ccu rren ce o f two o r m o re h o sp ita l sta ys. Th e gre a te r o ccu rre n ce o f h o sp ita liza tio n a m o n g m en , a lso o b served in o th er stu d ies (Bo u lts et a l., 1993) co u ld sign ify th a t m en seek m ed ica l assistan ce later th an wom en an d th at th e en try p oin t to th e h ealth system for eld erly m ale
resi-d en ts of Bam b u í cou lresi-d b e th e h osp ital. Th e as-so cia tio n b etween livin g a lo n e a n d th e o ccu r-ren ce of h osp ital stays, ob served in th e p resen t stu d y, wa s n o t fo u n d in p re vio u s stu d ie s ca r-rie d o u t in d e ve lo p e d co u n tr-rie s. Ou r re su lts su ggest th at in th e com m u n ity stu d ied , h osp ita liza tio n m a y b e a su b stitu te fo r la ck o f a d e q u ate h ou seh old care. Am on g th e en ab lin g in -d icators, we ob serve-d th at on ly th e rep ort of fi-n a fi-n cia l co fi-n stra ifi-n ts to o b ta ifi-n m ed ica tio fi-n wa s associated with th e occu rren ce of two or m ore h osp ital ad m ission s. In sp ite of th e lack of sim -ila r fin d in gs in o th e r stu d ie s, o u r re su lts a re con sisten t with th ose wh ich wou ld b e exp ected u n d er a h ea lth system th a t is still u n p rep a red to a tte n d to th e e ld e rly p o p u la tio n , a n d in
Tab le 3
Distrib utio n o f se le c t ind ic ato rs fo r the ne e d o f he alth se rvic e s utilizatio n, ac c o rd ing to the numb e r o f ho sp ital
ad missio ns d uring the last 12 mo nths amo ng o ld e r ad ults. Bamb uí, Minas Ge rais State , Brazil, 1997.
N umber of hospital admissions No ne O ne Two o r mo re p value * (n = 1,244) (n = 250) (n = 112)
% % %
N umber of visits to a doctor during the last 12 months
≤2 62,8 38,4 11,6
3 – 4 9,8 27,2 29,5
≥5 17,4 34,4 58,9 0,000
Use of prescribed medications during the last 3 months
No ne 24,1 8,4 3,6
1 – 2 30,8 25,6 13,4
3 – 4 27,2 30,4 36,6
≥5 17,9 35,6 46,4 0,000
Unable to perform routine activities because of a health problem during the last 2 weeks
Ye s 12,0 30,0 43,8
No 88,0 69,6 56,2 0,000
Having been bedridden during the last two weeks
Ye s 6,4 19,2 32,1
No 93,5 80,4 67,9 0,000
Capacity to walk 1.5km without tiring
Ye s 55,3 34,0 17,9
No 44,6 66,0 82,1 0,000
Disability in one or more ADLs**
Ye s 7,1 16,4 20,5
No 92,8 82,8 79,5 0,000
* Pe arso n c hi-sq uare
wh ich in cip ien t p h arm aceu tical assistan ce exists with ve r y h igh m e d ica tio n p rice s (Co n -sen d ey et al., 2000).
Th e re is co n siste n t e vid e n ce a m o n g o ld e r ad u lts th at h old in g a p rivate h ealth p lan is as-so cia te d with in cre a se d h e a lth se r vice u se in ge n e ra l (Co h e n e t a l., 1997; Hu rd & McGa rr y, 1997; Lim a -Co sta e t a l., in p re ss; Tra va sso s e t al., 2000). Th e sep arate effect of p rivate cover-age on h osp ital ad m ission s was in vestigated in on ly on e stu d y. In th is stu d y, carried ou t in th e Un ited States, it was d em on strated th at am on g p e o p le a ge d ≥70 ye a rs, p riva te cove ra ge wa s p o sitive ly a sso cia te d with h o sp ita l sta ys. In Bam b u í, we ob served a stron g an d p ositive as-so cia tio n b e twe e n h a vin g p riva te h e a lth p la n an d th e n u m b er of visits to a d octor or n u m b er o f p rescrib ed m ed ica tio n s u sed . Th is a sso cia -tio n wa s n o t su b sta n tia lly a ffe cte d b y a d ju st-m en ts for h ealth statu s an d oth er con fou n d in g
va ria b les. Ho sp ita liza tio n , o n th e o th er h a n d , wa s n o t fo u n d to b e a sso cia te d with p riva te covera ge (Lim a -Costa et a l., in p ress). Th e d iffe re n ce s b e twe e n th e se a n d th e Ba m b u í’s re -su lts cou ld b e exp lain ed , at least in p art, by th e (1) sm a ll p ro p o rtio n o f cove ra ge b y su p p le -m en ta r y h ea lth p la n s in th e stu d y p o p u la tio n (20%) co m p a red to th a t seen in th e Am erica n on e (70%) an d (2) by th e existen ce in Brazil of a p u b lic h ealth system (Sistem a Ún ico de Saú de) wh ich gu a ra n te e s fre e h o sp ita l ca re fo r th e wh o le p o p u la tio n . It is im p o rta n t to n o te th a t th e p ro p o rtio n o f th o se cove re d b y a p riva te h ea lth p la n in th e stu d y co m m u n ity is sim ila r to th at ob served in Brazil as a role (IBGE, 2000). Ou r re su lts sh ow d iffe re n ce s b e twe e n th e d e te rm in a n ts fo r th e o ccu rre n ce o f a sin gle h o sp ita l sta y a n d th o se fo r m u ltip le a d m is-sio n s. In gen era l, th e stu d y va ria b les a re m o st freq u en tly, a n d m ost stron gly, a ssocia ted with
Tab le 4
Distrib utio n o f se le c t ind ic ato rs fo r the ne e d o f he alth se rvic e s utilizatio n, ac c o rd ing to the numb e r o f ho sp ital
ad missio ns d uring the last 12 mo nths amo ng o ld e r ad ults. Bamb uí, Minas Ge rais State , Brazil, 1997.
N umber of hospital admissions No ne O ne Two o r mo re p value * (n = 1,244) (n = 250) (n = 112)
% % %
Self-perceived health status during the last 6 months
Ve ry g o o d / g o o d 26,3 18,0 2,7
Re aso nab le 49,1 43,6 23,2
Bad / ve ry b ad 20,3 29,6 61,6
No t info rme d ** 4,3 8,8 12,5 0,000
Report of medical history of coronary disease
Ye s 9,2 12,4 24,1
No 89,8 17,9 75,0 0,000
Report of medical history of hypertension
Ye s 55,7 59,2 67,9
No 44,3 40,8 32,1 0,007
Report of medical history of arthritis
Ye s 24,0 28,8 34,8
No 76,0 71,2 65,2 0,035
Report of medical history of diabetes
Ye s 10,6 12,4 18,8
No 89,4 87,6 81,2 0,031
Report of medical history of Chagas’s disease
Ye s 22,3 33,2 36,6
No 77,7 66,8 63,4 0,000
Tab le 5
Final re sults o f the multivariate analysis o f fac to rs asso c iate d with the o c c urre nc e o f ho sp ital
ad missio ns in the last 12 mo nths amo ng o ld e r ad ults. Bamb uí, Minas Ge rais State , Brazil, 1997.
O ne vs N one Two or more vs N one Hospital admissions hospital admissions O R (CI 95%) O R (CI 95%)
Indicators of predisposing
Ag e in ye ars (Re f: 60-69)
70-79 0,89 (0,64–1,24) 1,05 (0,62–1,78)
> 80 1,12 (0,71–1,76) 1,97 (1,05–3,68)
Ge nd e r (Re f: Fe male )
Male 0,86 (0,62–1,20) 1,82 (1,11–2,98)
Living alo ne (Re f: No )
Ye s 1,44 (0,98–2,12) 2,69 (1,53–4,74)
Indicators of enabling
Majo r p ro b le m in o b taining me d ic atio ns (Re f: No ne )
Financ ial p ro b le ms 1,16 (0,85–1,58) 2,47 (1,46–4,74)
O the rs 0,90 (0,51–1,61) 2,04 (0,92–4,56)
Indicators of need
Se lf-p e rc e ive d he alth d uring the last 6 mo nths (Re f: Ve ry g o o d / g o o d )
Re aso nab le 0,73 (0,48–1,11) 1,71 (0,49–5,95)
Bad / ve ry b ad 0,69 (0,42–1,12) 4,74 (1,38–16,29)
No t info rme d * 1,42 (0,72–2,79) 6,04 (1,49–24,48)
Numb e r o f visits to a d o c to r d uring the last 12 mo nths (Re f: ≤2)
3 – 4 1,70 (1,17–2,48) 4,22 (2,07–8,58)
≥5 2,03 (1,38–2,99) 6,63 (3,33–13,19)
Use o f p re sc rib e d me d ic atio ns d uring last 3 mo nths (Re f: No ne )
1 – 2 1,75 (1,02–3,00) 1,32 (0,38–4,58)
3 – 4 1,85 (1,05–3,23) 2,60 (0,80–8,43)
≥5 2,73 (1,53–4,88) 3,31 (1,01–10,82)
Re p o rt o f me d ic al histo ry o f c o ro nary d ise ase (Re f: No )
Ye s 0,99 (0,63–1,56) 2,04 (1,16–3,59)
Unab le to p e rfo rm ro utine ac tivitie s b e c ause o f a he alth p ro b le m in the p ast 2 we e ks (Re f: No )
Ye s 1,75 (1,17–2,61) 1,88 (1,12–3,16)
Having b e e n b e d rid d e n d uring last 2 we e ks (Re f: No )
Ye s 1,73 (1,07–2,81) 1,98 (1,10–3,54)
Cap ac ity to walk 1.5km witho ut tiring (Re f: Ye s)
No 1,52 (1,09–2,13) 1,91 (1,08–3,38)
O R = o d d s ratio ; CI = c o nfid e nc e inte rval – ad juste d fo r all variab le s liste d in the tab le using multino mial lo g istic re g re ssio n (1,579 ind ivid uals p artic ip ate d in final analysis) *p ro xy re sp o nd e nt
Acknowledgements
Th is stu d y was sp on sored by th e Fin an ciadora de Es-tu dos e Projetos(FINEP). H. L. G., E. U. an d M. F. F. L.-C. are fellows of th e Con selh o Nacion al de Desen volvi-m en to Cien tífico e Tecn ológico(CNPq ). Th is stu d y wou ld n ot h ave b een p ossib le with ou t th e collab ora-tion of th e p op u laora-tion of Bam b u í.
th e o ccu rre n ce o f m u ltip le h o sp ita liza tio n s. Th is ob servation is im p ortan t, sin ce p rogram s o f p re ve n tio n sh o u ld p rio ritize th e n e e d ie st m em b ers of th e eld erly p op u lation an d con se-q u e n tly, th o se with th e h igh e st p ro b a b ility o f m u ltip le h o sp ita l sta ys (Fre e b o rn e t a l., 1990; Zook & Moore, 1980).
With re ga rd to th e m e th o d o lo gy o f th is stu d y, all efforts were m ad e to avoid b ias, su ch as stim u lu s to p articip ate, d ou b le b lin d collec-tion of d ata, stan d ard izacollec-tion of p roced u res an d in stru m e n ts, a s we ll a s e xh a u stive tra in in g o f field team s. Th e resp on se rate in th is stu d y was h igh a n d th e p a rticip a n ts we re sim ila r to th e ge n e ra l p o p u la tio n o f o ld e r a d u lts o f Ba m b u í with re sp e ct to a ll th e ch a ra cte ristics in ve sti-ga te d : ge n d e r, a ge, m a rita l sta tu s, n u m b e r o f resid en ts p er d om icile, m on th ly fam ily in com e a n d sch oolin g, th u s gu a ra n teein g th e in tern a l valid ity of th e stu d y (Lim a-Costa et al., 2000b ). On th e oth er h an d , b ecau se th e in form ation on th e occu rren ce of h osp italization s refers to th e p re vio u s 12 m o n th s, th e p o ssib ility o f re ca ll b ias exists. It is u n likely th at th is h as in flu en ced o u r re su lts; th e ra te o f h o sp ita l a d m issio n s in th e stu d y p o p u la tio n (22%) wa s ve r y clo se to th at estim ated for all resid en ts of Bam b u í aged 60 o r ove r, re giste re d u n d e r th e p u b lic h e a lth system (26%) (DATASUS, 1997). Becau se th is is a crosssection al stu d y, it is im p ossib le to sep -arate cau se an d effect. Th u s, th e self-p erceived h ea lth sta tu s a s p o o r co u ld b e a co n seq u en ce of p reviou s h osp ital stays. However, it is p ossi-b le th a t th is wa s n o t tru e o f th e p resen t stu d y, sin ce th e im p o rta n ce o f self-p erceived h ea lth statu s in p red ictin g h osp italization s an d oth er e ve n ts re la te d to h e a lth p ro b le m s h a s b e e n con firm ed in p op u lation -b ased coh ort stu d ies (Bou lt et al., 1993; Korten et al., 1999). Su rvival b ias is always p ossib le in crosssection al stu d -ie s o f th e o ld e r a d u lt p o p u la tio n , th a t is, th e m o st in firm eld erly p eo p le a n d co n seq u en tly, th ose with th e h igh est n u m b er of h osp ital stays
m ay d ie earliest. Th e p resen ce of th is b ias cou ld d im in ish th e fo rce o f th e a sso cia tio n s a m o n g variab les, rein forcin g th ose fou n d in th is stu d y.
Conclusions
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