Factors associated with the care of elderly persons with Primary Health Care sensitive conditions

Objective: to analyze factors associated with the care of the elderly for Primary Health Care sensitive conditions in an Emergency Care Unit. Method: a cross-sectional study was carried out in a municipal district located in the northwest of the state of Paraná, Brazil, between May and November of 2015. A semi-structured instrument was used, consisting of three distinct blocks that addressed sociodemographic profile, characterization of care and the reasons that led the elderly to seek care in the unit. The data were submitted to Palavras-chave: Idoso. Serviços Médicos de Emergência. Atenção Primária à Saúde. Enfermagem Geriátrica. http://dx.doi.org/10.1590/1981-22562017020.170120


INTRODUCTION
The increase in life expectancy and the aging of the population have occurred in an accelerated manner in developing countries.In Brazil this phenomenon has been associated with an increase in the incidence and prevalence of chronic noncommunicable diseases, with 79% of Brazilians over 60 years of age reporting chronic health conditions [1][2][3] .The average burden of illness in years of life lost, adjusted for disability, is made up of infectious diseases (14.8%), external causes (10.2%) and chronic diseases (66.2%), constituting a triple disease burden 4 .
To meet the impact of the health needs of the elderly, the Ministry of Health created the National Health Policy for the Elderly in 2006.This is aimed at the promotion, prevention and recovery of health, based on the guidelines of the Sistema Único de Saúde (the Unified Health System) (SUS), seeking to develop individual and collective resolutive actions offered under Primary Health Care (PHC).Such actions should be carried out by the Family Health Strategy (FHS) in Basic Health Unit (BHU) coverage areas, supported by and linked to secondary and tertiary care for medium and high complexity referrals 5,6 .The Brazilian health system has adopted PHC as the preferred entry point for users into health services.However, this care point includes challenges that must be overcome, such as the insufficient provision of health services due to a lack of human and technological resources 7 .This fact subsequently affects demand in other health care facilities, such as Emergency Care Units (ECUs).
The ECUs offer an intermediate level of care, mediating referrals from the BHUs/FHS and hospitals to resolve acute or exacerbated clinical cases.A study carried out in southern Brazil revealed that most of the treatment provided by this high complexity service is not an ideal fit for urgent and emergency cases, creating confusion in the organizational structure, with emotional harm to patients and professionals, compromising the quality of care provided 8 .Treatment of PHC-sensitive conditions in ECUs is an evaluative indicator of the first level of health care, as efficient actions in the promotion and prevention of comorbidities result in a reduction in hospital admissions 9 .
Hospitalizations for Conditions Sensitive to Primary Care (HCSPCs) is a list developed by the Ministry of Health, published under Ordinance 221/2008, which indicates hospitalizations that would be avoidable if basic care services were effective and/or accessible 9 .HCSPCs can include, in certain conditions, non-controlled complications of a chronic illness or other conditions related to actions and services of prevention 10 .
Understanding the sensitive causes of the care provided in the ECUs allows the identification of the effects of PHC strategies, guiding the planning of interventions in such location, contributing greatly to the reduction of avoidable care, especially among the elderly population 11 .In view of the above, the objective of this study was to analyze the factors associated with the care of the elderly in ECUs for conditions sensitive to primary health care.

METHOD
A cross-sectional study was carried out between May and November 2015 in a municipal region located in the northwestern part of the state of Paraná, Brazil.The municipal region in question has an estimated population of 403,063 inhabitants, with 35 BHUs and 74 FHS teams, providing population coverage of 68.01% 12 .It has two functioning ECUs.The study was carried out in one of these units, which covers around 200,000 people and is registered with 11 BHUs in the municipal region 13 .
To calculate the sample, the number of elderly persons receiving care in the ECU in the four months prior to the beginning of data collection was surveyed, resulting in an average of 300 elderly individuals treated per month.A proportional stratified sample was performed, considering an estimate of error of 5% and a 95% confidence interval, plus 10% for possible losses.The final sample was 191 people.The selection technique was non-probabilistic based on traffic, or in other words, the elderly persons who attended the ECU were invited to participate in the study.Inclusion depended on the verification of adequate cognitive ability through the application of the Mini Mental State Exam (MMSE), with cognitive decline considered a score equal to or less than 24 points 14 .
In addition to assessing the cognitive status, the following inclusion criteria were adopted: people of both genders, aged 60 or over, who were not classified within the emergency criteria (green and blue color) of the risk classification of the Manchester Screening Protocol, which consists of classifying the patient according to their clinical condition, rather than order of arrival 15 .
After the classification of risk, the medical consultation and the confirmation that the treatment provided was primary care sensitive, the elderly were approached to verify if the diagnosis received was classified by the Tenth Revision of the International Classification of Diseases (ICD-10) and was included on the Brazilian HCSPC List, which has 19 diagnostic groups 9 .
Next, a semi-structured instrument was applied, divided into three distinct blocks.A pilot test was first carried out, which was submitted to modifications for qualification and adaptation to the context in which it was applied.
The first block of the instrument obtained information regarding the patient's identification and socio-demographic situation (gender; age; schooling; economic situation; referral BHU) and clinical data (existing morbidities; recurring visits to ECU; health plan).The second block dealt with the characterization of the care provided in the unit (risk classification; if referred by BHU and, if so, which professional carried out the referral; interviewee's perception about the need for referral, when referred; the health need described by the patient; and the diagnosis given, which would indicate the inclusion of the subject in the study, according to the ICD-10 and HCSPC).
The third block dealt with the reasons that led to seeking ECU care (frequency of seeking care in the BHU; if care was sought for a health complaint in the BHU before the ECU; reasons for not seeking care in the BHU; if care was sought in the BHU, what led to the non-resolution of the health complaint; how the individual evaluated the service in the BHU and in case of an unsatisfactory evaluation, what was the reason; opinions on what should be improved in the BHU; classification of the severity of the current health problem; if treatment was provided for the existing morbidity in the BHU; knowledge about the role of the BHU and ECU in providing care; expectation of care at the ECU).
The following dependent variables were adopted: Referred by BHU, through a BHU referral form confirming that care was sought in the BHU and for some reason the individual was referred; and Sought Care in BHU before ECU, where the participant was questioned about seeking care at the BHU before going to the ECU.The two dependent variables were evaluated from the responses of the interviewees and the absence of referral by the BHU for the majority of those who said they had sought the unit to treat their health problem.
The independent variables were divided into two blocks.The first evaluated the reasons why the individual did not seek treatment at the BHU: evaluation of the service performed by the BHU; presence of chronic morbidity, such as those requiring follow-up care; geographic location, with a walking distance of twenty to thirty minutes considered as a parameter, taking into account factors related to public transportation, such as cost and waiting time 16 ; lack of doctors; lack of confidence in BHU care; BHU service hours.
The second group evaluated the reasons that led to seeking care at the ECU: better technological and treatment resources of the ECU, such as the presence of available doctors for treatment and equipment for imaging tests; better service; the fact that appointments are not needed at the ECU; where individuals considered their clinical situation as an ECU case, after which they were questioned about their perception of their current state of health; fast service; possibility of examinations without the need to schedule a date and time, unlike the BHU; same day delivery of test results, again unlike the BHU, where the wait was approximately 10 days..All questionnaires were checked by the researchers for correction of possible typing errors and failures regarding the requirements considered for inclusion of the subject in the study.
A descriptive analysis of the sociodemographic data was performed in percentage and absolute numbers.The association between independent and dependent variables was verified using univariate logistic regression analysis using the Forward method, considering and inserted in ascending order those that remained in the model as they presented a value of p <0.20 and multivariate.The magnitude of the associations was estimated by Odds Ratio (OR), adopting the 95% interval as a measure of precision, considering the statistical significance of those with a value of p<0.05.
The study was developed in accordance with the ethical precepts recommended by Resolution 466/2012 of the National Health Council 17

RESULTS
A total of 191 elderly people were interviewed, the majority of whom were aged between 60 and 70 years (49.7%),female (56%) and lived with a partner (59.1%).A large part of the sample had <8 years of schooling (85.3%) and were retirees and/ or pensioners (78.5%).In terms of their clinical situation, the majority reported a chronic morbidity undergoing treatment (91.1%) and did not have a supplementary healthcare insurance plan (70.7%).
Regarding ICD-10 and HCSPC classification, most visits were due to diseases of the musculoskeletal system and connective tissue (47.6%), respiratory system illnesses (30.3%) and diseases of the digestive tract (10.9%), shown in Table 2.In univariate analysis, association with the variable sought BHU before the ECU found that elderly persons with chronic morbidity were 1.67 times more likely not to seek the BHU before the ECU.It was also found that the lack of doctors ( p=0.038) and lack of confidence in care ( p=0.025), reduced the chance of seeking the BHU for a consultation.The improved resources available ( p=0.038) and the fact that it is not necessary to schedule an appointment in the ECU ( p=0.002) also reduced the chance of seeking the BHU for consultation (Table 3).
The variable relating to elderly persons who were proven to have been referred by the BHU found that those with a chronic morbidity were 2.75 times more likely to be referred for care in the ECU, and that the lack of a physician resulted in a 2.81 greater chance of being referred for care in this unit (Table 3).
The results of multivariate analysis found that those with chronic morbidities were 1.42 times more likely to seek the ECU before the BHU and 1.65 times more likely to be referred to the ECU by the BHU.The lack of a doctor resulted in a 1.36 times greater chance of the elderly being referred to the ECU to meet their health needs (Table 4).to be continued

DISCUSSION
The FHS has been expanding in recent years.Data show that in 1998, the country had 2,195 teams registered with the Ministry of Health, covering 4.4% of the Brazilian population.At the beginning of 2016 this number had grown to 48,410 teams, with a population coverage of approximately 64%.In the state of Paraná, the numbers show an even more significant increase, with the number of teams increasing from 115 in 1998 to 2,868 in 2016, covering 68% of the population of the state 18 .
In the municipal region where the study was carried out, the data also showed an increase in the number of registered teams, with 75 currently in operation, providing population coverage of 68.01% 15,18.Despite this progress, there are still complex challenges in PHC to be overcome, such as using the information that is collected and provided by the FHS teams themselves.This disarticulation in the PHC micro-policy reflects on the health care provided, which, in many situations, is non-resolutive, causing the population to seek other levels of care to meet their health needs 7 .
The use of the HCSPC indicator allows the identification of the treatment provided and makes it possible to classify such treatment according to the diagnosis received.It relates the characteristics of the care provided to the attributes of PHC in preventing, diagnosing and treating diseases, as well as the monitoring and control of the health of people with chronic diseases.These actions, when effective, reduce the frequency of PHC-sensitive consultations at other levels of complexity 19 .
The study was aimed at the elderly population, as hospitalization expenses are higher in this age group due to their physiological, economic and social vulnerability 20 .The number of elderly women was slightly higher than the number of men, which is in line with studies on the profile of the population treated by health services 19,21 .The majority did not have more than eight years of schooling which puts them in a situation of social vulnerability.A study has demonstrated that low educational levels lead to lower rates of adherence to the treatment of chronic diseases, strongly influenced by the difficulties of access to health services 20 .
Elderly people who live with partners behave differently than those who live alone.This is due to the support between the couple, strengthening them against the aging process, which is often combined with chronic diseases.The leading role of women in the family group, resulting in greater control of the seeking of health care for their partners, is also relevant.This fact indicates the need to consider the differences of genres and family compositions to ensure a quality of health care that is more coherent with the unique needs of the users 22 .
It is important to emphasize the fundamental importance of modifying the approach of health professionals who treat the elderly population in PHC through continuous education and professional valorization, with a strengthening of the connection with and understanding of health needs.The present study showed that the elderly who sought the BHU before the ECU and who were undergoing treatment of a chronic morbidity were twice as likely to be referred to the ECU by a health professional.The same result was observed for the variable that investigated if the elderly were referred by a BHU professional due to the lack of doctors in the BHU.
PHC is considered to be the first contact with the health service and should be understood as the preferred entry point for the use of health actions and services.The health care provided at this level should consider the characteristics of the population, the behavior of the individual, and the technological resources available 23,24 .
Disconnected actions result in gaps in care for health service users, especially the elderly.The results of the present study were similar to the results of a study carried out with BHU users, health professionals and managers to evaluate the integrality of actions, which also revealed user dissatisfaction with the non-resolution of acute complaints, which can therefore be considered another reason for seeking care in UPA 23,24 .
The result indicated by the variable that investigates whether the elderly sought treatment at the BHU before the ECU reveals that elderly persons with chronic morbidities are more likely to seek the ECU first.Other studies have identified that many users seek the ECU because of the lack of medical professionals at the UBS 23,24 .Other factors include the guarantee of care by doctors and the availability of complementary exams, without the necessity of prior appointments, offered by the UPA 25 .
The fact that the ECU offers uninterrupted medical care represents a major challenge for public health, as the behavior of the population and the health professionals themselves is still influenced by the biomedical model of hegemony, with the concept of prevention little debated and/or understood by society.This situation reflects a need for health professionals to learn the importance of the articulation between levels of health services and actions, according to the guidelines of the Health Care Networks that indicate PHC as a model of care 26,27 .
The pyramid structure of the health system, adopted since the beginning of the 20 th century, with the flow of users at various levels of technological complexity, has not provided satisfactory results for the needs of the population.This model of care is not consistent with the health needs of the population, especially considering population aging and the prevalence of chronic diseases.The care coverage provided does not integrate with care actions, which have proven to be insufficient for the reality of Brazil. 28The inadequacy of ECU demand has been described both by national 28,29 and international researchers 30,31 .This result suggests that many units of medium complexity address situations that should be accommodated, solved and accompanied by basic care 28,32 .
The current structure of the SUS suggests it is more prepared to deal with acute than chronic conditions.This phenomenon has also been experienced in other parts of the world.A study carried out in Australia revealed that conditions sensitive to primary care were more prevalent in the over-60 population, and that the majority of visits dealt with complications of chronic and degenerative diseases 30 .The results of this study indicated diseases of the musculoskeletal system and connective tissue and those of the respiratory and circulatory system as the main reasons for seeking care in ECU.
Also corroborating the results of the present study, a literature review study pointed out that doctor availability and the continuity of primary care can reduce hospitalization for acute problems arising from chronic morbidities, such as arterial hypertension and diabetes Mellitus 31 .This finding reinforces the need for longitudinal care for those with chronic morbidities, in order to avoid possible complications, thus avoiding re-hospitalizations One limitation of the present study was the size of the sample and the fact that it was performed in only one of the two UPAs located in the municipal region, which makes it impossible to generalize the results, which are therefore limited only to the population in question.In addition, another limitation was that the research was carried out within the unit, which may result in constraint and consequently allow the environment to influence the participants' responses.It is reiterated that the study indicates factors that led to treatment and not hospitalizations due to conditions sensitive to primary care, which may assist the understanding of professionals regarding the demand for services more suited to another level of care.

CONCLUSION
The results of this study allow us to conclude that elderly persons with chronic diseases are more likely to seek BHUs and to be referred by primary care professionals.It was also found that the lack of doctors in the BHU is a factor that leads to an increase in the demand for treatment for primary care sensitive conditions.
There are therefore barriers between the health needs of the elderly and the provision of services, which shows that the reorganization of primary health care will not be sufficient to solve the health problems of the population, and that other means of organizing the flow of treatment are required.There is an urgent need for administrative policies that implement strategies to minimize ECU care for conditions sensitive to primary care, especially for the elderly population, which has specific characteristics and needs continuous and comprehensive care, both of which are found in primary care.
and its design was approved by the Standing Committee on Ethics in Research with Human Beings (Approval no.137/2014).All the participants signed two copies of a Free and Informed Consent Term (FICF).

Table 2 .
Characterization of care requirements of elderly persons classified with complaints sensitive to primary care who sought treatment at the ECU.Paraná, 2015.
*Some elderly persons had more than one complaint; **ICD: International Classification of Diseases

Table 3 .
Univariate analysis of factors associated with seeking care in the ECU.Paraná, Brazil, 2015.
* Variables with p-value <0.20 were included in multivariate analysis; OR: Odds Ratio; CI: Confidence interval; BHU: Basic Health Unit; ECU: Emergency Care Unit.Continuation of Table3

Table 4 .
Multivariate analysis of factors associated with elderly persons seeking care at the ECU.Paraná, Brazil, 2015.
OR: Odds Ratio; CI: Confidence Interval; BHU: Basic Health Unit; ECU: Emergency Care Unit.