Hospital mortality in older patients in the Brazilian Unified Health System, Southeast region

Cordeiro, Paula; Martins, Mônica

doi:10.11606/S1518-8787.2018052000146

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original Article • Rev. Saúde Pública 52 • 2018 • https://doi.org/10.11606/S1518-8787.2018052000146 copy

Hospital mortality in older patients in the Brazilian Unified Health System, Southeast region

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To evaluate factors associated with hospital death in older inpatients for specific diseases of the circulatory system in the Brazilian Unified Health System considering the risk-adjusted hospital mortality as an indicator of effectiveness.

METHODS

The data were extracted from the Brazilian Hospital Information System. A total of 385,784 hospitalizations of older were selected for hypertensive diseases, ischemic heart disease, congestive heart failure, and stroke in the Brazilian Southeast region between 2011 and 2012. Age, sex, emergency admission, principal diagnosis, and two comorbidity indexes were included in the logistic regression for the risk adjustment of hospital death. The analyses were developed at two levels: hospitalization and hospital.

RESULTS

A greater chance of death was observed with increasing age, emergency hospitalizations, stroke, presence of comorbidities, especially pneumonia and weight loss, hospitalizations for clinical care, and use of intensive care units. The risk-adjusted hospital mortality rate was 11.1% in for-profit private hospitals, 12.3% in non-profit private hospitals, and 14.4% in public hospitals, but there was great variability among the hospitals. The hospital standardized mortality ratio (ratio between observed and predicted deaths) ranged from 103.3% in non-profit private hospitals to 118.2% in for-profit private hospitals.

CONCLUSIONS

Although the information source has its shortcomings, the ability for discrimination of the risk adjustment model was reasonable. The variability in the risk-adjusted hospital mortality was great and comparatively higher in for-profit private hospitals. Despite the limits, the results favor the use of the risk-adjusted hospital mortality in the monitoring of the quality of hospital care provided to the older adult.

Aged; Cardiovascular Diseases; Hospital Mortality; Risk Factors; Quality of Health Care; Unified Health System

Characteristics	Hospitalizations (%)	Number of deaths (crude mortality rate %)
Number of cases (%)	385,784 (100.0)	50,317 (13.0)
Sex
Male (%)	196,975 (51.1)	24,702 (12.5)
Female (%)	188,809 (48.9)	25,615 (13.6)
Mean age (years and standard deviation)	72.91 (8.6)	75.6 (9.1)
Age group in years (n, %)
60–64	78,378 (20.3)	6,866 (8.8)
65–70	90,219 (23.4)	9,328 (10.3)
71–74	59,296 (15.4)	7,187 (12.1)
75–80	77,239 (20.0)	11,088 (14.4)
81–84	39,142 (10.1)	6,770 (17.3)
85–90	31,036 (8.0)	6,413 (20.7)
91–100	10,474 (2.7)	2,665 (25.4)
Principal diagnosis (%)
Hypertensive diseases
I10 Essential hypertension (primary)	31,901 (8.3)	717 (2.2)
I11 Hypertensive heart disease	2,266 (0.6)	94 (4.1)
I15 Secondary hypertension	4,260 (1.1)	167 (3.9)
Ischemic heart disease
I20 Angina pectoris	50,584 (13.1)	1,579 (3.1)
I21 Acute myocardial infarction	38,247 (9.9)	7,844 (20.5)
I22 Recurrent acute myocardial infarction	944 (0.2)	164 (17.4)
I24 Other acute ischemic heart diseases	16,214 (4.2)	660 (4.1)
I25 Chronic ischemic heart disease	8,536 (2.2)	454 (5.3)
Congestive heart failure (%)
I50 Congestive heart failure	141,831 (36.8)	18,739 (13.2)
Stroke
I60 Subarachnoid hemorrhage	1,867 (0.5)	621 (33.3)
I61 Intracranial hemorrhage	5,770 (1.5)	1,951 (33.8)
I62 Other nontraumatic intracranial hemorrhages	1,572 (0.4)	587 (37.3)
I63 Cerebral infarction	6,980 (1.8)	1,453 (20.8)
I64 Stroke not specified as hemorrhagic or ischemic	74,812 (19.4)	15,287 (20.4)
Residents of the Southeast region (%)
Yes	385,328 (99.9)	50,266 (13.0)
Type of admission
Elective	37,428 (9.7)	2,432 (6.5)
Emergency	348,356 (90.3)	47,885 (13.7)
Comorbidities
Yes	53,177 (13.8)	9,915 (18.6)
Charlson Comorbidity Index (score)
Index = 0	372,765 (96.6)	47,920 (12.9)
Index = 1	10,487 (2.7)	1,703 (16.2)
Index ≥ 2	2,532 (0.7)	694 (27.4)
Elixhauser Comorbidity
Absence	354,933 (92.0)	45,443 (12.8)
Presence	30,851 (8.0)	4,874 (15.8)
Care Process
Type of procedure (%)
Medical	334,225 (86.6)	46,925 (14.0)
Surgical	51,559 (13.4)	3,392 (6.6)
Use of the ICU (%)
Yes	69,798 (18.1)	15,656 (22.4)
No	315,986 (81.9)	34,661 (11)
Length of stay
Mean (SD) – days	6.88 (8.3)	8.93 (12.3)
Range (days)
≤ 1	40,380 (10.5)	10,808 (26.8)
2–7	240,074 (62.2)	21,246 (8.8)
8–15	70,588 (18.3)	10,122 (14.3)
16–30	26,363 (6.8)	5,581 (13.0)
31–45	5,544 (1.4)	1,503 (27.1)
45–309	2,835 (0.7)	1,057 (37.3)
Total reimbursement value (R$)
Mean (SD)	2,020.75 (3,415.80)	2,548.60 (4,486.16)
Mode	699.46	669.46
Median	731.46	848.19
Variation	21.98–73,385.46	40.38–73,385.46
Hospital Ownership
Public	143,885 (37,3)	24,562 (17.1)
For-profit Private	26,271 (6,8)	1,662 (6.3)
Non-profit Private	215,628 (55.9)	24,093 (11.2)
State
Minas Gerais (%)	117,604 (30.5)	13,065 (11.1)
Espírito Santo (%)	16,121 (4.2)	1,749 (10.8)
Rio de Janeiro (%)	55,352 (14.3)	9,271 (16.7)
São Paulo (%)	196,707 (51.0)	26,232 (13.3)

Variable	Model 1^c		Model 2^d		Model 3^e

	OR	95%CI	OR	95%CI	OR	95%CI
Sex
Male	1	-	1	-	1	-
Female	1.041	1.021–1.062	1.043	1.022–1.064	1.042	1.021–1.064
Age group (years)
60–64	1	-	1	-	1	-
65–70	1.179	1.140–1.219	1.184	1.144–1.226	1.190	1.148–1.233
71–74	1.382	1.333–1.433	1.409	1.358–1.463	1.434	1.381–1.490
75–80	1.637	1.584–1.692	1.661	1.605–1.719	1.697	1.639–1.757
81–84	1.959	1.886–2.034	1.991	1.916–2.070	2.072	1.992–2.156
85–90	2.378	2.287–2.472	2.428	2.333–2.527	2.556	2.453–2.663
91–100	3.089	2.930–3.256	3.219	3.048–3.400	3.501	3.311–3.703
Principal diagnosis
I50 Congestive heart failure	1	-	1	-	1	-
Hypertensive diseases
I10 Essential hypertension (primary)	0.155	0.143–0.167	0.086	0.080–0.093	0.087	0.080–0.094
I11 Hypertensive heart disease	0.323	0.262–0.397	0.201	0.162–0.249	0.190	0.153–0.236
I15 Secondary hypertension	0.306	0.261–0.357	0.203	0.173–0.238	0.207	0.177–0.244
Ischemic heart disease
I20 Angina pectoris	0.264	0.250–0.278	0.196	0.186–0.207	0.203	0.192–0.215
I21 Acute myocardial infarction	1.938	1.881–1.998	1.548	1.500–1.598	1.128	1.090–1.168
I22 Recurrent acute myocardial infarction	1.733	1.461–2.056	1.470	1.230–1.757	1.073	0.890–1.293
I24 Other acute ischemic heart diseases	0.390	0.359–0.423	0.305	0.280–0.332	0.310	0.284–0.339
I25 Chronic ischemic heart disease	0.458	0.416–0.505	0.283	0.256–0.313	0.357	0.321–0.398
Stroke
I60 Subarachnoid hemorrhage	4.034	3.652–4.456	3.272	2.950–3.630	3.205	2.878–3.570
I61 Intracranial hemorrhage	3.799	3.586–4.025	3.294	3.102–3.498	3.473	3.264–3.697
I62 Other nontraumatic intracranial hemorrhages	4.198	3.778–4.665	3.691	3.308–4.118	4.898	4.356–5.508
I63 Cerebral infarction	1.784	1.678–1.896	1.628	1.528–1.734	1.773	1.662–1.891
I64 Stroke not specified as hemorrhagic or ischemic	1.793	1.750–1.836	1.685	1.644–1.727	1.740	1.697–1.785
Type of admission
Elective	1	-	1	-	1	-
Emergency	1.297	1.238–1.359	1.601	1.527–1.680	1.424	1.355–1.496
Comorbidity index
Score = 0	1	-	1	-	1	-
Score = 1	1.655	1.565–1.750	1.514	1.430–1.604	1.515	1.428–1.606
Score ≥ 2	2.913	2.656–3.195	2.571	2.337–2.828	2.463	2.232–2.717
Presence of comorbidity
No	1	-	1	-	1	-
Yes	2.136	2.054–2.222	1.876	1.800–1.954	1.965	1.884–2.049
Elixhauser Comorbidity^a a Ministério da Saúde (BR). DATASUS: morbidade hospitalar do SUS (SIH/SUS). Brasília (DF); 2015 [cited 2015 Jun 26]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0203&id=6926 (no/yes)
Arrhythmia	0.772	0.679–0.878	0.771	0.675–0.881	0.681	0.594–0.781
Hypertension	0.419	0.395–0.446	0.450	0.422–0.479	0.460	0.431–0.490
Other neurological disease	0.505	0.371–0.686	0.499	0.363–0.685	0.489	0.354–0.677
Hypothyroidism	0.254	0.116–0.554	0.248	0.112–0.552	0.221	0.098–0.496
Weight loss	1.822	1.209–2.745	1.756	1.142–2.700	2.021	1.313–3.113
Deficiency anemia	0.298	0.136–0.652	0.302	0.136–0.667	0.369	0.167–0.816
Another specific prevalent comorbidity: Pneumonia^b (no/yes)	1.494	1.377–1.620	1.481	1.361–1.610	1.467	1.346–1.599
Length of stay (days)
≤ 1			1	-	1	-
2–7			0.150	0.145–0.154	0.126	0.122–0.130
8–15			0.226	0.218–0.234	0.161	0.155–0.167
16–30			0.348	0.334–0.363	0.222	0.213–0.232
31–45			0.480	0.448–0.514	0.288	0.268–0.310
45–309			0.742	0.681–0.810	0.437	0.399–0.479
Use of ICU
No					1	-
Yes					4.095	3.986–4.207
Type of care
Medical					1	-
Surgical					0.390	0.371–0.410
Constant	0.07		0.263		0.292

Ownership	Characteristics of the hospitals^a a Ministério da Saúde (BR). DATASUS: morbidade hospitalar do SUS (SIH/SUS). Brasília (DF); 2015 [cited 2015 Jun 26]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0203&id=6926
Public	Number of hospitals	357
	Mean volume of cases (SD)	399.2 (533.8)
	Volume variation	1–4,959
	Crude hospital mortality rate (variation)	16.7 (0.80–100.00)
	Risk-adjusted hospital mortality rate 1 (variation)^b	14.4 (2.70–34.18)
	Adjusted hospital mortality rate 2 (variation)^c	12.7 (1.27–31.85)
	Hospital standardized mortality ratio (95%CI)	116.4 (108.32–124.20)
	Ratio variation	5.9–824.4
	Median	104.9
	SD	76.2
For-profit Private	Number of hospitals	73
	Mean volume of cases (SD)	361.4 (483.34)
	Volume variation	2–2,333
	Crude hospital mortality rate (variation)	10.0 (0.40–100.00)
	Risk-adjusted hospital mortality rate 1 (variation)^b	11.1 (2.26–19.24)
	Adjusted hospital mortality rate 2 (variation)^c	10.1 (30.04–28.60)
	Hospital standardized mortality ratio (95%CI)	118.2 (39.20–197.12)
	Ratio variationo	4.5–2,892.6
	Median	59.3
	SD	338.4
Non-profit Private	Number of hospitals	685
	Mean volume of cases (SD)	311.95 (475.45)
	Volume variation	1–7,521
	Crude hospital mortality rate (variation)	11.6 (0.47–100.00)
	Risk-adjusted hospital mortality rate 1 (variation)^b	12.3 (1.27–31.84)
	Adjusted hospital mortality rate 2 (variation)^c	11.9 (0.96–41.51)
	Hospital standardized mortality ratio (95%CI)	103.3 (80.42–126.12)
	Ratio variation	3.8–7,885.2
	Median	85.7
	SD	304.6

State	Number of hospitals^a a Ministério da Saúde (BR). DATASUS: morbidade hospitalar do SUS (SIH/SUS). Brasília (DF); 2015 [cited 2015 Jun 26]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0203&id=6926 (%)	Crude hospital mortality rate (variation)	Risk-adjusted hospital mortality rate 1^b (variation)	Adjusted hospital mortality rate 2^c (variation)
Minas Gerais	441 (39.6)	10.9 (0.53–100.00)	13.1 (2.82–26.64)	12.0 (2.87–41.51)
Espírito Santo	60 (5.4)	10.3 (0.58–40.00)	12.1 (5.28–32.60)	11.5 (4.33–33.44)
Rio de Janeiro	165 (14.8)	17.7 (0.40–100.00)	13.1 (1.27–34.18)	13.5 (0.96–35.23)
São Paulo	449 (40.3)	14.0 (0.47–100.00)	13.1 (2.37–27.22)	13.0 (1.40–28.47)

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence: Paula Cordeiro. Rua Paulo Barreto, 71 Botafogo. 22280-010 Rio de Janeiro, RJ, Brasil. E-mail: paulab.cordeiro@gmail.com