Evaluation of comprehensive care for older adults in primary care services

Placideli, Nádia; Castanheira, Elen Rose Lodeiro; Dias, Adriano; Silva, Pedro Alcântara da; Carrapato, Josiane Lozigia Fernandes; Sanine, Patricia Rodrigues; Machado, Dinair Ferreira; Mendonça, Carolina Siqueira; Zarili, Thais Fernanda Tortorelli; Nunes, Luceime Olivia; Monti, José Fernando Casquel; Hartz, Zulmira Maria de Araújo; Nemes, Maria Ines Battistella

doi:10.11606/s1518-8787.2020054001370

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Original Article • Rev. Saúde Pública 54 • 2020 • https://doi.org/10.11606/s1518-8787.2020054001370 copy

Evaluation of comprehensive care for older adults in primary care services

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To evaluate the performance of comprehensive care for older adults in primary care services in the Brazilian Unified Health System in the state of São Paulo, Brazil.

METHODS

A total of 157 primary care services from five health regions in midwestern São Paulo responded, from October to December 2014, the pre-validated 2014 questionnaire for primary care services assessment and monitoring. We selected 155 questions, based on national policies and guidelines on this theme. The responses indicate the service performance in older adults’ care, clustered into three areas of analysis: health care for active and healthy aging (45 indicators, d1), chronic noncommunicable diseases care (89 indicators, d2), and support network in aging care (21 indicators, d3). Performance was measured by the sum of positive (value 1) or negative (value 0) responses for each indicator. Services were clustered according to k-means of the performance scores of each domain. After weighting the domains (Z tests), we estimated the associations between the scores of each domain and independent management variables (typology, planning and evaluation of services), with simple and multiple linear regression.

RESULTS

Chronic noncommunicable diseases care (d2) showed, for all clusters, better average performance (55.7) than domains d1 (35.4) and d3 (39.2). Service performance in the general area of planning and evaluation associates with the performance of older adults’ care.

CONCLUSIONS

The evaluated services had incipient implementation of comprehensive care for older adults. The evaluation framework can contribute to processes to improve the quality of primary health care.

Health Services for Older Adults; Comprehensive Health Care; Primary Health Care; Health Services Research; Brazilian Unified Health System

Dimension	Thematic cores	Independent variables
Planning	Type of service	- Family Health Unit (FHU) - Traditional Basic Health Unit (BHU) - BHU with Family Health Strategy (FHS) - BHU with Community Health Agents Program (CHAP) - BHU or FHU integrated to emergency care - Health outpost (PAS)
	Geographic location	- Rural - Central urban - Peripheral urban
	Planning of the service coverage area	- Area defined by participatory planning, considering local reality and ease of access - Area defined by the service team - No definition of the coverage area
	Matrix support	- Family health support center (FHSC) - Multiprofessional team - It is not carried out by any instance
Evaluation	Use of epidemiological data for planning	- By municipal management and unit, for planning - By municipal management, but inappropriate by the unit - Not used
	Participation in evaluations in the last three years	- Participated - Did not participate
	Developments based on the evaluations performed	- Annual teamwork plan - Activity planning and reprogramming with participation of the multiprofessional team - Report on the problems identified for the municipal secretariat - The service lacked access to the results - No evaluation was carried out
	Changes induced by evaluations	- Assistance organization - Service management - Assistance management and organization - No changes were reported - Did not participate in any previous evaluation

Domains	Groups	N	Mean	SD	Minimum	Maximum
Health care for active and healthy aging (d1)	1	20	68,4	9,0	47,5	83,1
	2	106	35,4	13,9	5,9	71,2
	3	31	12,0	5,3	1,9	23,7
Chronic noncommunicable diseases care (d2)	1	19	73,6	3,8	66,0	80,0
	2	105	55,7	8,0	37,0	71,0
	3	31	35,4	7,5	20,0	49,0
Structure and support network in aging care (d3)	1	20	51,0	11,1	33,9	67,8
	2	106	39,2	10,1	12,7	59,3
	3	31	30,2	8,8	12,7	50,8

Domain	Indicators	G1	G2	G3	p
d1	Cognitive evaluation	90.0_b	38.7_c	9.7_a	0.001
	Depressive conditions evaluation	90.0_b	43.4_c	3.2_a	0.001
	Functional evaluation	85.0_b	19.8_c	0.0_a	0.001
	Fall prevention guidelines	95.0_b	60.4_c	0.0_a	0.001
	Guidelines on food and nutrition	100.0_b	72.6_c	6.5_a	0.001
	Guidelines on urinary incontinence	95.0_b	48.1_c	0.0_a	0.001
	Guidelines on the importance of physical activity	95.0_b	42.5_c	0.0_a	0.001
	Actions on sexuality and sexually transmitted diseases (STD)	90.0_b	32.1_c	0.0_a	0.001
	Guidelines on menopause and andropause	95.0_b	44.3_c	6.5_a	0.001
	Guidelines on oral health	95.0_b	68.9_c	16.1_a	0.001
	Guidelines on older adults’ rights	70.0_b	29.2_c	3.2_a	0.001
	Guidelines on violence against older adults	85.0_b	32.1_c	0.0_a	0.001
	Investigation of alcohol and other drugs abuse	75.0_b	23.6_c	0.0_a	0.001
	Home care	100.0_b	59.4_a	29.0_a	0.001
	Support for older adults in long-term care facilities	50.0_b	15.1_b	9.7_a	0.001
	Dental care for older adults	75.0_b	52.8_a	25.8_a	0.002
	Health education in the community in the promotion of healthy aging	55.0_b	21.7_c	3.2_a	0.001
	Health education in the service in the promotion of healthy aging	80.0_b	22.6_c	0.0_a	0.001
	Prevention and screening of prostate cancer and other neoplasia in man health care	100.0_b	81.1_c	35.5_a	0.001
	Care and rehabilitation of male urinary incontinence	70.0_b	17.9_c	3.2_a	0.001
	Prevention and education on male sexual dysfunction	100.0_b	42.5_c	6.5_a	0.001
	Guidelines on andropause in man health care	50.0_b	15.1_a	3.2_a	0.001
	Early detection of breast cancer as a scheduled action for women's health	100.0_b	82.1_c	64.5_a	0.006
	Identification and guidance of older adults’ caregivers	95.0_b	44.3_c	12.9_a	0.001
	Evaluation of the caregiver's family functionality	90.0_b	44.3_c	9.7_a	0.001
	Investigation of the caregiver's social support network	75.0_b	34.9_c	9.7_a	0.001
	Informative support for caregivers	75.0_b	55.7_b	19.4_a	0.001
	Evaluation of the caregiver’s stress	85.0_b	26.4_c	0.0_a	0.001
	Support group for caregivers	30.0_b	5.7_a	3.2_a	0.001
	Detection of violence against older adults by identifying symptoms	100_b	72.6_c	32.3_a	0.001
	Detection of violence against older adults by listening to reports from other users	90.0_b	74.5_b	38.7_a	0.001
	Detection of violence against older adults by their own declaration	90.0_b	71.7_a.b	54.8_a	0.025
	Detection of violence against older adults by a case discussion	85.0_b	40.6_c	9.7_a	0.001
	Detection of violence against older adults by team training	80.0_b	24.5_c	0.0_a	0.001
	Detection of violence against older adults by home visits	100.0_b	60.4_c	32.3_a	0.001
	Arraignment to the Social Assistance Reference Center (SARC) and the Specialized Social Assistance Reference Center (SSARC) after the identification of violence against older adults	95.0_b	67.9_c	35.5_a	0.001
	Caregivers’ care and follow-up after the identification of violence against older adults	75.0_b	34.0_c	6.5_a	0.001
	Compulsory notification after the identification of violence against older adults	55.0_b	27.4_a	35.5_a.b	0.049
	Interdisciplinary care with service professionals after the identification of violence against older adults	85.0_b	35.8_c	12.9_a	0.001
	Intersectoral follow-up of cases after the identification of violence against older adults	50.0_b	7.5_a	0.0_a	0.001
d2	Scheduling periodic returns at the end of each care as a routine action for chronic noncommunicable diseases (CNCD)	100.0_b	72.6_a	54.8_a	0.002
	Clarification and guidance of examination results as a routine action for CNCD	100.0_b	90.6_b	41.9_a	0.001
	Prescription renewal without medical appointment as a routine action for CNCD	100.0_b	80.2_c	41.9_a	0.001
	Active search for people with CNCD	85.0_b	54.7_c	12.9_a	0.001
	Physical activities guidance as a routine action for CNCD	100.0_b	81.1_c	25.8_a	0.001
	Conducting support groups for people with CNCD	90.0_b	32.1_c	0.0_a	0.001
	Registration of patients at high risk as a routine action for CNCD	65.0_b	33.0_c	3.2_a	0.001
	Referral to specialized service and its follow-up as a routine action for CNCD	90.0_b	36.8_c	9.7_a	0.001
d2	Referral to adherent group in the service as a strategy to non-adherents with CNCD	30.0_b	10.4_a	6.5_a	0.027
	Active search for non-adherents to the treatment with CNCD	85.0_b	60.4_c	25.8_a	0.001
	Home visit as a strategy for non-adherents to the treatment with CNCD	95.0_b	59.4_c	19.4_a	0.001
	Team discussion on approach alternatives as a strategy for non-adherents with CNCD	85.0_b	37.7_c	6.5_a	0.001
	Discussion of cases of non-adherents with CNCD with external supervision	25.0_b	11.3_b	0.0_a	0.019
	Convocation of missing adults with chronic diseases at risk of complications	90.0_b	49.1_a	38.7_a	0.001
	Follow-up with protocol in the care of people with arterial hypertension	75.0_b	44.3_c	9.7_a	0.001
	Three blood pressure measurements at different times in the care of people with arterial hypertension	90.0_b	61.3_c	35.5_a	0.001
	Diet guidance in the care of people with arterial hypertension	100.0_b	96.2_b	74.2_a	0.001
	Obesity treatment and/or prevention in the care of people with arterial hypertension	100.0_b	67.9_c	25.8_a	0.001
	Periodic exam requests in the care of people with arterial hypertension	100.0_b	86.8_b	61.3_a	0.001
	Introduction of non-drug therapy as a first alternative in the care of people with arterial hypertension	85.0_b	56.6_c	16.1_a	0.001
	Cardiovascular risk assessment for drug therapy in the care of people with arterial hypertension	100.0_b	57.5_c	22.6_a	0.001
	Group activities in the care of people with arterial hypertension	85.0_b	50.9_c	6.5_a	0.001
	Guidance for physical activities in the care of people with arterial hypertension	100.0_b	84.0_b	45.2_a	0.001
	Guidance and support for smoking cessation in the care of people with arterial hypertension	95.0_b	64.2_c	19.4_a	0.001
	Investigation of alcohol and other drugs abuse in the care of people with arterial hypertension	85.0_b	50.0_c	0.0_a	0.001
	Potassium as a routine examination for people with arterial hypertension	100.0_b	92.5_b	71.0_a	0.001
	Triglycerides as a routine examination for people with arterial hypertension	100.0_a.b	96.2_b	83.9_a	0.017
	Uric acid as a routine examination for people with arterial hypertension	100.0_b	91.5_b	77.4_a	0.020
	Funduscopy as a routine examination for people with arterial hypertension	55.0_b	18.9_c	3.2_a	0.001
	Dispensation of hydrochlorothiazide in the care of people with arterial hypertension	100.0_b	86.8_b	67.7_a	0.004
	Dispensation of furosemide in the care of people with arterial hypertension	100.0_b	86.8_b	67.7_a	0.004
	Dispensation of spironolactone in the care of people with arterial hypertension	95.0_b	68.9_c	48.4_a	0.002
	Dispensation of atenolol in the care of people with arterial hypertension	65.0_a.b	72.6_b	45.2_a	0.017
	Dispensation of propranolol in the care of people with arterial hypertension	100.0_b	87.7_b	58.1_a	0.001
	Dispensation of methyldopa in the care of people with arterial hypertension	95.0_b	79.2_b	58.1_a	0.006
	Dispensation of amlodipine besylate in the care of people with arterial hypertension	65.0_b	59.4_b	25.8_a	0.002
	Dispensation of hydralazine hydrochloride in the care of people with arterial hypertension	20.0_b	4.7%_a	6.5_a.b	0.049
	Dispensation of captopril in the care of people with arterial hypertension	100.0_b	87.7_b	64.5_a	0.001
	Dispensation of enalapril in the care of people with arterial hypertension	100.0_b	76.4_a	64.5_a	0.013
	Follow-up with protocol in the care of people with type 2 diabetes mellitus	75.0_b	47.2_c	16.1_a	0.001
	Diet guidance for people with type 2 diabetes mellitus	100.0_b	96.2_b	80.6_a	0.003
	Obesity treatment and/or prevention in the care of people with type 2 diabetes mellitus	95.0_b	80.2_b	32.3_a	0.001
	Periodic exam requests in the care of people with type 2 diabetes mellitus	100.0_b	90.6_b	67.7_a	0.001
	Control, evaluation and guidance of foot care for people with type 2 diabetes mellitus	100.0_b	82.1_c	41.9_a	0.001
	Training for self-application of insulin in the care of people with type 2 diabetes mellitus	100.0_b	82.1_c	51.6_a	0.001
	Glycometer supply in the care of people with type 2 diabetes mellitus	90.0_b	75.5_b	48.4_a	0.002
	Group activities for people with type 2 diabetes mellitus	95.0_b	52.8_c	6.5_a	0.001
	Physical activity guidance for people with type 2 diabetes mellitus	100.0_b	84.0_b	32.3_a	0.001
	Guidance and support for smoking cessation for people with type 2 diabetes mellitus	90.0_b	55.7_c	12.9_a	0.001
	Fasting blood sugar test as a routine examination for people with type 2 diabetes mellitus	100.0_a.b	100.0_b	87.1_a	0.001
	Serum creatinine as a routine examination for people with type 2 diabetes mellitus	95.0_b	86.8_b	71.0_a	0.039
	Glycated hemoglobin every three months, then every six months, as a routine examination for people with type 2 diabetes mellitus	95.0_b	84.9_b	54.8_a	0.001
	Funduscopy as a routine examination for people with type 2 diabetes mellitus	75.0_b	40.6_c	6.5_a	0.001
	Electrocardiography as a routine examination requested for people with type 2 diabetes mellitus	85.0_b	66.0_a.b	48.4_a	0.026
d2	Dispensation of regular insulin in the care of people with type 2 diabetes mellitus	90.0_b	77.4_b	58.1_a	0.024
	Dispensation of metformin in the care of people with type 2 diabetes mellitus	95.0_b	79.2_b	58.1_a	0.006
	Dispensation of glibenclamide in the care of people with type 2 diabetes mellitus	100.0_b	80.2_c	54.8_a	0.001
	Diagnosis and referrals to other levels of care as an action to bedridden people care	90.0_b	62.3_c	22.6_a	0.001
	Periodic visits with support team as an action to bedridden people care	90.0_b	54.7_c	25.8_a	0.001
	Periodic visits with physician as an action to bedridden people care	95.0_b	61.3_a	41.9_a	0.001
	Home procedures as an action to bedridden people care	100.0_b	84.0_b	64.5_a	0.004
	Oral hygiene guidelines as an action to bedridden people care	95.0_b	55.7_c	9.7_a	0.001
	Home dental care as an action to bedridden people care	60.0_b	17.9_c	3.2_a	0.001
	Guidelines on social rights as an action to bedridden people care	90.0_b	30.2_c	9.7_a	0.001
	Prevention and follow-up in cases of alcohol and other drug use and abuse as an action to bedridden people care	85.0_b	8.5_a	0.0_a	0.001
	Registration in medical records of domiciliary actions as an action to bedridden people care	100.0_b	71.7_c	22.6_a	0.001
	Family care in case of death as an action to bedridden people care	95.0_b	24.5_a	12.9_a	0.001
	Discussion of cases with health network as an action to bedridden people care	85.0_b	39.6_c	9.7_a	0.001
d3	Vehicle for service use	75.0_b	39.6_c	19.4_a	0.001
	Conducting electrocardiography in the service	80.0_b	49.1_a	38.7_a	0.012
	Conducting rapid HIV test in the service	75.0_b	49.1_c	22.6_a	0.001
	Older adults’ health as a theme of continuing training for the service team	55.0_b	36.8_b	6.5_a	0.001
	Church–linked groups as a support or development of collaborative actions for older adults	30.0_b	10.4_a	6.5_a	0.027
	SARC as a support for referrals and/or development of collaborative actions for older adults	90.0_b	72.6_a.b	58.1_a	0.045
	SSARC as a support for referrals and/or development of collaborative actions for older adults	55.0_b	31.1_a	22.6_a	0.047

Domain	Indicators	G1	G2	G3	p
d1	Mammography request every two years for women aged between 50 and 74 without risk factors or alteration of physical examination	50.0_a	32.1_a	32.3_a	0.290
	Use of protocol as a strategy for detecting violence against older adults	20.0_b	13.2_a.b	3.2_a	0.166
	Use of Dial 100 as a procedure performed after the identification of violence against older adults	20.0_a	8.5_a	6.5_a	0.222
	Arraignment to the police as a procedure performed after the identification of violence against older adults	45.0_a	24.5_a	25.8_a	0.166
	Referral to the family health support center or the support team as a procedure performed after the identification of violence against older adults	25.0_b	17.0_a.b	3.2_a	0.075
d2	Blood pressure and/or blood glucose control at specific times and days and according to necessity as a routine action for chronic noncommunicable diseases (CNCD)	100.0_a	90.6_a	83.9_a	0.160
	Referral to reference service as a strategy to non-adherents with CNCD	25.0_a	26.4_a	12.9_a	0.293
	Discharge for non-adherents with CNCD	10.0_a	6.6_a	6.5_a	0.854
	Call for missing people in activities and appointments scheduled for altered medical test results	73.7_a	72.4_a	67.7_a	0.861
	Non-use of protocol in care for people with arterial hypertension	30.0_a	38.7_a	38.7_a	0.755
	Urine analysis as a routine examination for people with arterial hypertension	100.0_a	93.4_a	83.9_a	0.083
	Serum creatinine as a routine examination for people with arterial hypertension	100.0_a	90.6_a	83.9_a	0.160
	Fasting blood sugar test as a routine examination for people with arterial hypertension	95.0_a	95.3_a	93.5_a	0.928
	Total cholesterol and fractions (LDL and HDL) as a routine examination for people with arterial hypertension	100.0_a	98.1_a	96.8_a	0.713
	Electrocardiography as a routine examination for people with arterial hypertension	100.0_a	94.3_a	83.9_a	0.056
	Dispensation of mannitol in the care of people with arterial hypertension	15.0_b	6.6_a.b	0.0_a	0.099
	Dispensation of metoprolol succinate in the care of people with arterial hypertension	20.0_a	23.6_a	22.6_a	0.939
	Dispensation of verapamil hydrochloride in the care of people with arterial hypertension	30.0_a	19.8_a	22.6_a	0.592
	Dispensation of sodium nitroprusside in the care of people with arterial hypertension	10.0_a	6.6_a	9.7_a	0.778
	Non-use of protocol in the care of people with type 2 diabetes mellitus	25.0_a	37.7_a	38.7_a	0.528
	Annual examination of total cholesterol and fractions and triglycerides in the care of people with type 2 diabetes mellitus	90.0_b	69.8_a.b	58.1_a	0.052
	Urine analysis as a routine examination for people with type 2 diabetes mellitus	100.0_b	91.5_a.b	80.6_a	0.058
	Microalbuminuria as a routine examination for people with type 2 diabetes mellitus	60.0_b	50.0_b	29.0_a	0.056
	Total cholesterol and fractions (LDL and HDL) as a routine examination for people with type 2 diabetes mellitus	100.0_a	92.5_a	83.9_a	0.111
	Triglycerides as a routine examination for people with type 2 diabetes mellitus	95.0_a	92.5_a	80.6_a	0.110
	Dispensation of NPH insulin in the care of people with type 2 diabetes mellitus	90.0_a	79.2_a	67.7_a	0.157
d3	Accessibility in service for people with disabilities (PWD) or with mobility impairments	85.0_a	74.5_a	61.3_a	0.153
	Adapted restroom for people with disabilities or with mobility impairments	80.0_b	53.8_a	58.1%_a.b	0.093
	Wheelchair in service	100.0_a	89.6_a	83.9_a	0.177
	Application of DT vaccine in service	90.0_b	78.3_a.b	64.5_a	0.093
	Application of influenza vaccine in service	90.0_b	79.2_a.b	64.5_a	0.082
	Conduction of blood glucose test in service	100.0_a	99.1_a	93.5_a	0.115
	Clinical laboratory tests collected in service	75.0_a	67.0_a	51.6_a	0.174
	Access to the municipal or regional network of services for older adults’ care	45.0_b	29.2_a.b	16.1_a	0.082
	Neighborhood associations as a support or development of collaborative actions for older adults	15.0_a	5.7_a	3.2_a	0.212
	Senior living communities as a support for referrals and/or development of collaborative actions for older adults	20.0_a	26.4_a	12.9_a	0.274
	Day-care center as a support for referrals and/or development of collaborative actions for older adults	5.0_a	5.7_a	6.5_a	0.975
	Specialized service as a support for referrals and/or development of collaborative actions for older adults	10.0_a	15.1_a	6.5_a	0.413
	Non-governmental organizations as a support for referrals and/or development of collaborative actions for older adults	10.0_a	7.5_a	3.2_a	0.606
	Other services as a support for referrals and/or development of collaborative actions for older adults	20.0_b	5.7_a	12.9_a.b	0.081

Domain	Variable	SLR	MLR

		p-value	Coefficient

			Beta	95%CI		p-value
d1 (r² aj. = 0,82)	Traditional Basic Health Unit	< 0.001	0.198	20.590	-5.591	0.001
	Report on the problems identified for the municipal secretariat as the main unfolding of the evaluations	0.198	0.030	15.026	6.709	0.013
	The service lacked access to the evaluation results as the main unfolding of the evaluations	0.227	0.006	11.430	9.812	0.029
	Organization of assistance as evaluation–induced modification	0.238	0.052	45.379	8.615	0.036
	Management and organization of assistance as evaluation–induced modification	< 0.001	0.044	16.755	4.497	0.030
	Did not participate in any previous evaluation	0.001	0.003	-6.504	6.918	0.027
d2 (r² aj. = 0,96)	Traditional Basic Health Unit	0.001	-0.051	-26.845	-4.549	0.004
	Non-use of epidemiological data for the service planning	0.017	-0.106	-14.023	1.282	0.006
	Organization of assistance as evaluation–induced modification	0.234	-0.024	-8.156	2.664	< 0.001
	Service management evaluation–induced modification	0.086	-0.030	-12.008	1.744	< 0.001
	Management and organization of assistance as evaluation–induced modification	< 0.001	-0.009	-7.612	5.322	< 0.001
	No evaluation–induced changes occurred in the service	0.077	-0.018	-18.964	14.800	< 0.001
	Did not participate in any previous evaluation	< 0.001	0.319	42.771	90.010	< 0.001
d3 (r² aj. = 0,93)	Organization of assistance as evaluation–induced modification	0.247	3.627	18.534	63.012	< 0.001
	Service management evaluation–induced modification	0.043	2.729	8.451	52.981	0.007
	Management and organization of assistance as evaluation–induced modification	< 0.001	3.769	19.155	61.471	< 0.001
	No evaluation–induced changes occurred in the service	0.039	2.891	10.467	55.824	0.004
	Did not participate in any previous evaluation	0.007	2.944	10.756	54.840	0.004

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E-mail: revsp@usp.br

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[1] Correspondence: Nádia Placideli Universidade Estadual Paulista. Faculdade de Medicina - Campus de Botucatu. Departamento de Enfermagem Av. Prof. Mário Rubens Guimarães Montenegro, s/n - UNESP - Anexo Vermelho. Campus de Botucatu - Botucatu/SP - CEP 18618687 Email: nadiaplacideli@gmail.com