Evaluation of comprehensive care for older adults in primary care services

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

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

RESUMO

OBJETIVO

Avaliar o desempenho da atenção integral ao idoso em serviços de atenção primária do Sistema Único de Saúde no estado de São Paulo, Brasi

lMÉTODOS

Um total de 157 serviços de atenção primária de cinco regiões de saúde do centro-oeste paulista respondeu, de outubro a dezembro de 2014, o instrumento pré-validado Questionário de Avaliação e Monitoramento de Serviços de Atenção Básica 2014. Foram selecionadas 155 questões, com base nas políticas e diretrizes nacionais sobre essa temática. As respostas indicam o desempenho do serviço na atenção ao idoso, agrupadas em três domínios de análise: atenção à saúde para o envelhecimento ativo e saudável (45 indicadores, d1), atenção às doenças crônicas não transmissíveis (89 indicadores, d2) e rede de apoio na atenção ao envelhecimento (21 indicadores, d3). A medida de desempenho foi a soma de respostas positivas (valor 1) ou negativas (valor 0) para cada indicador. Os serviços foram agrupados segundo k-médias dos escores de desempenho de cada um dos domínios. Após a ponderação dos domínios (testes Z), foram estimadas as associações entre os escores de cada domínio e variáveis independentes de gestão (tipologia, planejamento e avaliação dos serviços), por meio de regressão linear simples e múltipla.

RESULTADOS

A atenção às doenças crônicas não transmissíveis (d2) mostrou, para todos os agrupamentos, melhor desempenho médio (55,7) do que os domínios d1 (35,4) e d3 (39,2). O desempenho do serviço na área geral de planejamento e avaliação esteve associado ao desempenho da atenção ao idoso.

CONCLUSÕES

Os serviços avaliados apresentaram implementação incipiente da atenção integral ao idoso. O quadro avaliativo pode contribuir para processos de melhoria da qualidade da atenção primária à saúde.

Serviços de Saúde para Idosos; Assistência Integral à Saúde; Atenção Primária à Saúde; Pesquisa sobre Serviços de Saúde; Sistema Único de Saúde

INTRODUCTION

Primary health care (PHC) is pointed out as a priority to assist and monitor older adults’ health status, besides acting in the prevention of health problems and in the health promotion to a healthy aging. Accordingly, the World Health Organization (WHO) proposed in 2004 that primary care services should adapt to serve older adults properly11. World Health Organization. Active aging: towards age-friendly primary health care. Geneva; WHO; 2004 [citado 23 jun 2016]. Available from: http://apps.who.int/iris/bitstream/10665/43030/1/9241592184.pdf
http://apps.who.int/iris/bitstream/10665...
. In Brazil, in view of the population aging, the Ministry of Health published in 2007 the Caderno de Atenção Básica (Primary Care Guide) no. 19, guiding primary care teams for a greater resolution of the older adults’ demands22. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Envelhecimento e saúde da pessoa idosa. Brasília, DF; 2007 [citado 15 maio 2015]. (Série A, Normas e Manuais Técnicos) (Cadernos de Atenção Básica, 19). Available from: http://bvsms.saude.gov.br/bvs/publicacoes/abcad19.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
.

The expansion of the PHC public network and the need to strengthen management structures and to redefine roles in the three spheres of government have driven the institutionalization of agreement and evaluation mechanisms to assist the decision–making process and to improve the public health system33. Onocko-Campos RT, Campos GWS, Ferrer AL, Corrêa CRS, Madureira PR, Gama CAP, et al. Avaliação de estratégias inovadoras na organização da Atenção Primária à Saúde. Rev Saude Publica. 2012;46(1):43-50. https://doi.org/10.1590/S0034-89102011005000083
https://doi.org/10.1590/S0034-8910201100...
, 44. Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad Saude Publica. 2014;30(12):2643-55. https://doi.org/10.1590/0102-311X00187113
https://doi.org/10.1590/0102-311X0018711...
. Especially since the last decade, evaluation and monitoring strategies are essential tools to measure the effectiveness of health systems at all levels of care44. Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad Saude Publica. 2014;30(12):2643-55. https://doi.org/10.1590/0102-311X00187113
https://doi.org/10.1590/0102-311X0018711...
.

In this context, evaluating services for the older adults’ health care, especially in PHC, is increasingly important to know the advances in implementing the recommendations of the Primary Care Guide no. 192. They cover promotion and prevention actions to achieve active and healthy aging, management of chronic noncommunicable diseases (CNCD) and networking.

National and international studies conducted to evaluate the older adults’ care in PHC indicate the need to expand preventive practices and health promotion, infrequent and low diverse in actions, in addition to the importance to build networks of comprehensive care to older adults’ health, ordained by PHC services55. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, RS, Brasil. Rev Bras Med Fam Comunidade. 2013;8(29):264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826...
. The QualiAB 2014 instrument (Questionnaire for Primary Care Services Assessment and Monitoring) proposes, among its indicators for the comprehensive evaluation of primary care services, those directed to older adults’ care1111. Placideli N, Castanheira ERL. Atenção à saúde da pessoa idosa e ao envelhecimento em uma rede de serviços de Atenção Primária. Kairós Gerontol. 2017;20(2):247-69. https://doi.org/10.23925/2176-901X.2017v20i2p247-269
https://doi.org/10.23925/2176-901X.2017v...
.

Despite the political and technological propositions available in the country for PHC performance in this segment, literature on the actions effectively implemented evaluating their organization and supply is still scarce55. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, RS, Brasil. Rev Bras Med Fam Comunidade. 2013;8(29):264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826...
, as well as on the challenges generated by population aging for these services55. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, RS, Brasil. Rev Bras Med Fam Comunidade. 2013;8(29):264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826...
. Most studies evaluate the actions developed in PHC according to the older adults’ perception of the care they received, and those who take the organization of actions in a comprehensive way and directed to the work carried out by the teams as an evaluative focus are rare.

This study aims to evaluate the performance of comprehensive care for older adults in primary health care services according to their managers and professionals, as well as to analyze the relationship between performance and indicators of health planning and evaluation.

METHODS

Cross-sectional evaluative research based on the analysis of the results of QualiAB application in 2014. The evaluation occurred in PHC services located in five health regions in midwestern São Paulo: Bauru, Jaú, Lins, Polo Cuesta and Vale do Jurumirim, totaling 68 municipalities and 303 services, according to CNES1212. Ministério da Saúde (BR). Cadastro Nacional de Estabelecimentos de Saúde. Brasília, DF; s.d. [citado 1 dez 2018]. Available from: http://cnes.datasus.gov.br/pages/estabelecimentos/consulta.jsp
http://cnes.datasus.gov.br/pages/estabel...
(eliminating duplicate and non–corresponding registrations to PHC services).

This is a convenience sample, consisting of five health regions chosen for a census application of QualiAB 2014. The regions are in areas close to the higher education institution responsible for the research, with which previous partnerships were made in projects to support the management and evaluation of PHC services using the same instrument1313. Castanheira, ERL, Nemes MIB, Zarili TFT, Sanine PR, Corrente JE. Avaliação de serviços de Atenção Básica em municípios de pequeno e médio porte no estado de São Paulo: resultados da primeira aplicação do instrumento QualiAB. Saude Debate. 2014;38(103): 679-91. https://doi.org/10.5935/0103-1104.20140063
https://doi.org/10.5935/0103-1104.201400...
. A total of 157 services distributed in 41 municipalities adhered to the project, representing 63% of the existing in the period1212. Ministério da Saúde (BR). Cadastro Nacional de Estabelecimentos de Saúde. Brasília, DF; s.d. [citado 1 dez 2018]. Available from: http://cnes.datasus.gov.br/pages/estabelecimentos/consulta.jsp
http://cnes.datasus.gov.br/pages/estabel...
. Adhesion was voluntary since no financial incentive or prize was offered in the process.

Teams of each health service answered QualiAB 2014 online, after the municipal manager and the managers or responsible for each service adhered. This application integrated the instrument upgrade and revalidation process, originally validated in 20071313. Castanheira, ERL, Nemes MIB, Zarili TFT, Sanine PR, Corrente JE. Avaliação de serviços de Atenção Básica em municípios de pequeno e médio porte no estado de São Paulo: resultados da primeira aplicação do instrumento QualiAB. Saude Debate. 2014;38(103): 679-91. https://doi.org/10.5935/0103-1104.20140063
https://doi.org/10.5935/0103-1104.201400...
.

This QualiAB version consists of 126 multiple–choice questions, which generate composite indicators for the overall evaluation of PHC services, to cover the diverse set of health actions attributed to primary care, as provided for the National Primary Care Policy (PNAB— Política Nacional de Atenção Básica )1616. Ministério da Saúde (BR). Portaria Nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Brasília (DF): 2017 [citado 1 dez 2018]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
http://bvsms.saude.gov.br/bvs/saudelegis...
. It is a questionnaire developed to evaluate and monitor services regarding the structure and organization of the work process by indicators of care and management, regardless of the type of unit, that is, organized both according to the Family Health Strategy and by another type of arrangement between the various existing compositions1313. Castanheira, ERL, Nemes MIB, Zarili TFT, Sanine PR, Corrente JE. Avaliação de serviços de Atenção Básica em municípios de pequeno e médio porte no estado de São Paulo: resultados da primeira aplicação do instrumento QualiAB. Saude Debate. 2014;38(103): 679-91. https://doi.org/10.5935/0103-1104.20140063
https://doi.org/10.5935/0103-1104.201400...
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To this study, we chose and categorized the variables of QualiAB 2014 related to older adults’ health and aging care, thus defining 155 performance indicators. First, we identified and analyzed documents on this evaluation object, to enable its delimitation and build a logical-theoretical model that will guide the selection of indicators and their organization in domains. Although a program specifically designed for the older adults’ health is not instituted, as it is with other segments, guidelines and technical standards are available, which allow delimiting the actions that should be developed at this level of care1717. Ramos NP. Avaliação da atenção à saúde da pessoa idosa e ao envelhecimento em serviços de Atenção Primária [tese]. Botucatu: Faculdade de Medicina de Botucatu, Universidade Estadual Júlio de Mesquita Filho; 2018. .

We used the following documents: the Brazilian Health Policy for Older Adults (PNSPI— Política Nacional de Saúde da Pessoa Idosa )1818. Ministério da Saúde (BR). Portaria Nº 2.528, de 19 de outubro de 2006. Aprova a Política Nacional de Saúde da Pessoa Idosa. Brasília, DF; 2006 [citado 15 maio 2015]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html
http://bvsms.saude.gov.br/bvs/saudelegis...
, and the guidelines of the Ministry of Health published in the Primary Care Guide no. 192, in the Strategic Action Plan to Tackle Noncommunicable Diseases (NCD) in Brazil 2011–20221919. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Análise de Situação de Saúde. Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília, DF; 2011 [citado 15 maio 2015]. (Série B. Textos Básicos de Saúde). Available from: http://bvsms.saude.gov.br/bvs/publicacoes/plano_acoes_enfrent_dcnt_2011.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
, and in the technical manual Guidelines for the care of people with chronic diseases in Health Care Nets and in priority lines of care 2020. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Diretrizes para cuidados de pessoas com doenças crônicas nas redes de atenção à saúde e nas linhas de cuidados prioritárias. Brasília, DF; 2013 [citado 15 maio 2015]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes%20_cuidado_pessoas%20_doencas_cronicas.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
.

The QualiAB 2014 selected indicators were gathered according to three large sets of attributes considered essential to comprehensive care for the older adults’ health and aging in three domains: health care for active and healthy aging (d1, composed of 45 indicators), chronic noncommunicable diseases (CNCD) care (d2, composed of 89 indicators), and structure and support network in the aging care (d3, composed of 21 indicators).

Statistical analysis was conducted from different strategies. To each domain, a final score equivalent to the sum of dichotomous responses was assigned to the indicators that compose it. Value 1 refers to achievement and value 0 to non-achievement. We also defined three clusters (performance groups) using k-means related to the scores, to achieve maximum heterogeneity between the different groups and maximum internal homogeneity in each group2121. Tanaka OY, Drumond Júnior M, Cristo EB, Spedo SM, Pinto NRS. Uso da análise de clusters como ferramenta de apoio à gestão do SUS. Saude Soc. 2015;24(1):34-45. https://doi.org/10.1590/S0104-12902015000100003
https://doi.org/10.1590/S0104-1290201500...
. The three groups were organized by decreasing gradation of k-means obtained by the services, naming group 1 (G1) the services with the highest k-means, and group 3 (G3) those with the lowest k-means.

The second stage tested the association of each group composition with the responses to 30 QualiAB 2014 indicators that characterize the activities related to the service planning and general evaluation, shown in Chart 1 . The associations between the selected indicators and each of the three domains were estimated using chi-square tests followed by Z tests. As each domain consisted of different amounts of indicators (with maximum scores of 45, 89 and 21, respectively), the scores were standardized to keep them within the same magnitude scale.

Chart 1
Independent variables related to the planning and evaluation dimensions used in simple and multiple linear regression models, based on the questionnaire QualiAB 2014.

With the standardized scores, simple and multiple linear regression models were adjusted. As independent variables we had the service selected characteristics (Chart 1), and as response variables, the scores of each domain. The variables that obtained r2 values above 50% and significance levels of the model lower than 0.25 with normal distribution of residues in simple adjustments were carried to multiple adjustment, in which those with r2 above 80%, p < 0.05 values, and normal residues distribution were maintained. All steps of statistical analysis were developed with SPSS software version 20.0.

This study was approved by the Research Ethics Committee of the Faculdade de Medicina de Botucatu, Universidade Estadual de São Paulo by opinion no. 855,404.

RESULTS

Among the 157 PHC services evaluated, according to self-classification, Family Health Units (FHU; 42%) prevailed, followed by traditional Basic Health Units (BHU; 36.9%). The Family Health Strategy (FHS) was present in 8.2% of the BHU, and the Community Health Agent Program (CHAP), in 8.9%; 1.2% were traditional BHU or FHU integrated to emergency care, and 2.5% of the services chose to be classified with other modalities.

All 45 QualiAB 2014 indicators elected to domain 1 (d1) cover actions of promotion, prevention and assistance related to older adults; aging care in the prevention of health problems and in health promotion; strategies and actions in situations of violence against older adults; and attention to older adults’ caregivers. Domain 2 (d2) clustered 89 indicators corresponding to routine actions for people with CNCD and strategies to approach non-adherence to treatment; programmatic care, routine examinations and medications available to people with arterial hypertension and to people with type 2 diabetes mellitus; and actions for bedridden people care. In domain 3 (d3), we clustered 21 indicators related to infrastructure, supplies and professional qualifications that enable prevention and health promotion for an active and healthy aging, in addition to the network of services for older adults’ health care in collaborative work with primary care. The services distribution in the different groups (G1, G2 and G3) and the average performance according to each analysis domain are shown in Table 1 .

Table 1
Performance of primary health and aging care services for older adults, clustered according to k-means, per analysis domain, 2014 (n = 157).

In all three areas most services are concentrated in group 2 of performance, although with variations between the means achieved. The highest values were obtained in the domain of CNCD care (d2), in which the highest means are also visible.

In domain 1, it is noteworthy the services presented the lowest means among the groups with worst performances. In domain 3, group 1 obtained its lowest mean (51.0) among all domains. Notably, most services perform less than half of the set of indicators evaluated, composing groups 2 (39.2; d2) and 3 (30.2; d3). The slightest difference between the means of the groups in this domain suggests the services show less differentiation in relation to the indicators.

Tables 2 and 3 show the frequencies of indicators by domain and by performance group (G1, G2 and G3), allowing to deepen the understanding of central tendency measures. The differences between groups are significant in 72.9% (113) out of the 155 indicators, shown in Table 2 . Services belonging to G1 have high percentages of achievement of most of the actions evaluated; however, they too lacks totality for a comprehensive care for older adults’ health and aging.

Table 2
Percentage distribution (%) of performance indicator frequencies in older adults’ health and aging care in primary care services, according to domain (d1, d2 and d3) and performance groups (G1, G2 and G3), with significant p-values, 2014 (n = 157).

In domain 2, we observe the smallest percentage differences of achievement between the quality groups. The smaller response percentages are among the indicators of domain 3, focused on equipment with which services can share actions and care directed to older adults and promote the team’s continued training on older adults’ health—for example, the Specialized Social Assistance Reference Center (SSARC).

Table 3 features the indicators with no significance according to the chi-square test. This includes 27% (42) out of the 155 indicators. Notably, most of them are in domain 3, in which non-differentiation between groups is due to the availability of infrastructure and, on the other hand, to the lack of support from the services network to older adults’ care in most services.

Table 3
Percentage distribution (%) of performance indicators frequencies in older adults’ health and aging care in primary care services, according to domain (d1, d2 and d3) and performance groups (G1, G2 and G3), with non-significant p-values, 2014 (n = 157).

Table 4 provides adjustments to the simple and multiple linear regression (SLR and MLR) models for the domain scores for the health planning and evaluation variables that remained in the final multiple model, although others may have been adjusted according to the criterion defined in the method. Analyzing the independent variables related to the differentiation of quality groups for domain 1 (d1), we found that the service typology, the consequences of evaluations, and changes induced by evaluations are distinctive to compose groups with different performance.

Table 4
Adjustments of simple and multiple linear regression (SLR and MLR) models for the domain scores by general planning activity variables and service evaluation and typology, based on the questionnaire for primary care services assessment and monitoring (QualiAB) 2014 (n = 157).

For domain 2 (d2), the independent variables that reflect relation with the differentiation of quality groups relate to the services typology, the use of epidemiological data, and the changes induced by evaluations, to form groups with better or worse performances. In domain 3 (d3), independent variables that influence on the formation of the different performance quality groups for the set of indicators evaluated relate to the changes induced by evaluations.

It is important to note the adjustment model (r2) for each domain proved to be great, a fact corroborated by its results: 0.82%, 0.96% and 0.93%, respectively.

DISCUSSION

The results point to a better performance of PHC services in actions related to chronic noncommunicable diseases, matching with results from other studies2222. Van Olmen J, Marie KG, Christian D, Clovis KJ, Emery B, Maurits VP, et al. Content, participants and outcomes of three diabetes care programmes in three low and middle income countries. Prim Care Diabetes. 2015;9(3):196-202. https://doi.org/10.1016/j.pcd.2014.09.001
https://doi.org/10.1016/j.pcd.2014.09.00...
, 2323. Rabetti AC, Freitas SFT. Avaliação das ações em hipertensão arterial sistêmica na atenção básica. Rev Saude Publica. 2011;45(2):258-68. https://doi.org/10.1590/S0034-89102011005000007
https://doi.org/10.1590/S0034-8910201100...
and reflecting the undifferentiation with which services fulfill the scope of actions in older adults’ health and aging care. Prevention and promotion actions were incompletely incorporated into few services, and most of them lack a support network to collaborative work, resulting on the lack of comprehensive care for older adults’ health in the sample.

This is corroborated by a descriptive study previously conducted by the authors with analysis of the response frequencies of these primary care services on the indicators. This study identified: the presence of a support group for older adults’ caregivers in few services (8.2%), the use of a protocol to attend cases of violence against older adults (12.1%), a record with differentiated risk for people with chronic conditions (31.2%), and inclusion of older adults’ health as the subject of continuing education for the professional team (33.1%)1111. Placideli N, Castanheira ERL. Atenção à saúde da pessoa idosa e ao envelhecimento em uma rede de serviços de Atenção Primária. Kairós Gerontol. 2017;20(2):247-69. https://doi.org/10.23925/2176-901X.2017v20i2p247-269
https://doi.org/10.23925/2176-901X.2017v...
.

Aging and longevity are strongly associated with developing chronic diseases, because aging without any chronic disease is rare2424. Veras RP, Caldas CP, Cordeiro HA. Modelos de atenção á saúde do idoso: repensando o sentido da prevenção. Physis. 2013;23(4):1189-213. https://doi.org/10.1590/S0103-73312013000400009
https://doi.org/10.1590/S0103-7331201300...
. However, old age cannot be reduced to a set of illnesses in the actions developed in PHC.

The relevance of preventive actions for comprehensive care to the adult’s—and especially to the older adult’s—health apparently is a consensus; however, notably, practices tend to be restricted to the care of more prevalent CNCD55. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, RS, Brasil. Rev Bras Med Fam Comunidade. 2013;8(29):264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826...
, 2424. Veras RP, Caldas CP, Cordeiro HA. Modelos de atenção á saúde do idoso: repensando o sentido da prevenção. Physis. 2013;23(4):1189-213. https://doi.org/10.1590/S0103-73312013000400009
https://doi.org/10.1590/S0103-7331201300...
. It is obviously not a question of minimizing the importance of the quality of care for people with chronic diseases, but of emphasizing that older adults are often inserted in this set of problems, which does not automatically offer the necessary for them and for their aging.

Naturally, the actions performed by the HiperDia program, instituted since 2002 by the Brazilian Ministry of Health for people with systemic arterial hypertension and diabetes mellitus2525. Ministério da Saúde (BR), Secretaria de Políticas de Saúde, Departamento de Ações Programáticas Estratégicas. Plano de reorganização da atenção a hipertensão arterial e ao diabetes mellitus: manual de hipertensão arterial e diabetes. Brasília, DF; 2002 [citado 15 maio 2015]. (Série C. Projetos, Progamas e Relatórios, 59). Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/miolo2002.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
, were implemented because chronic diseases represent one of the main demands for continuous follow-up in PHC services. However, to invest in improving the quality of this care is necessary, because the services fail to fully perform the recommended, as in relation to periodic funduscopy or foot care for people with diabetes, which occur in few services evaluated1111. Placideli N, Castanheira ERL. Atenção à saúde da pessoa idosa e ao envelhecimento em uma rede de serviços de Atenção Primária. Kairós Gerontol. 2017;20(2):247-69. https://doi.org/10.23925/2176-901X.2017v20i2p247-269
https://doi.org/10.23925/2176-901X.2017v...
.

In this study, it is possible to verify that the guidelines for health prevention and promotion are not being implemented in older adults and aging care, which also occurs with other stages of the life cycle and health demands2626. Nasser MA, Nemes MIB, Andrade MC, Prado RR, Castanheira ERL. Avaliação na atenção primária paulista: ações incipientes em saúde sexual e reprodutiva. Rev Saude Publica. 2017;51:77. https://doi.org/10.11606/S1518-8787.2017051006711
https://doi.org/10.11606/S1518-8787.2017...
, 2727. Sanine PR, Zarili TFT, Nunes LO, Dias A, Castanheira ERL. Do preconizado à prática: oito anos de desafios para a saúde da criança em serviços de atenção primária no interior de São Paulo. Cad Saude Publica. 2018;34(6): e00094417. https://doi.org/10.1590/0102-311X00094417
https://doi.org/10.1590/0102-311X0009441...
. In this sense, monitoring older adults’ functional capacity becomes a strategic indicator for health services2323. Rabetti AC, Freitas SFT. Avaliação das ações em hipertensão arterial sistêmica na atenção básica. Rev Saude Publica. 2011;45(2):258-68. https://doi.org/10.1590/S0034-89102011005000007
https://doi.org/10.1590/S0034-8910201100...
, especially for primary care services, which are potentially instrumentalized by the use of scales for functional and cognitive evaluation, among others, available in the Primary Care Guide no. 192.

Studies on older adults’ care by primary care services conducted in Rio de Janeiro (RJ)2828. Motta LB, Aguiar AC, Caldas CP. Estratégia Saúde da Família e a atenção ao idoso: experiência em três municípios brasileiros. Cad Saude Publica. 2011;27(4):779-86. https://doi.org/10.1590/S0102-311X2011000400017
https://doi.org/10.1590/S0102-311X201100...
and in Santos (SP)2929. Costa MFBNA, Ciosak SI. Atenção integral na saúde do idoso no Programa Saúde da Família: visão dos profissionais de saúde. Rev Esc Enferm USP. 2010;44(2):437-44. https://doi.org/10.1590/S0080-62342010000200028
https://doi.org/10.1590/S0080-6234201000...
found a great disarticulation of the health services network in general and, especially, an absence of an older adults’ health care network, which hampers the supplying of this population health needs. Associations between the performance of the services in older adults’ care and the performance of activities indicative of local planning and evaluation show the importance of service management in determining the technical performance of programmatic activities. In particular, the low incorporation and use of data resulting from evaluation processes highlights the need to strengthen and improve monitoring and evaluation practices as subsidies for reprogramming technical actions of care, such as those directed to older adults’ health and to aging.

The limits of a cross-sectional study carried out in certain health regions and with a convenience sample should inhibit generalization of results. However, it brings significant elements in the face of the evaluation gap and the absence of instruments directed to assess older adults’ and aging care. In this sense, the study proved feasible to use an instrument that does not focus on this assessment but uses it as part of the diverse set of actions under the responsibility of PHC services.

It is necessary to advance in the provision of practices aimed at older adults by PHC services that seek to face the health demands of this population, aiming to understand the needs arising from aging and to collaborate so that individuals achieve old age with independence, autonomy and productivity2929. Costa MFBNA, Ciosak SI. Atenção integral na saúde do idoso no Programa Saúde da Família: visão dos profissionais de saúde. Rev Esc Enferm USP. 2010;44(2):437-44. https://doi.org/10.1590/S0080-62342010000200028
https://doi.org/10.1590/S0080-6234201000...
, because most chronic diseases that affect older adults have their main risk factor in their own age2424. Veras RP, Caldas CP, Cordeiro HA. Modelos de atenção á saúde do idoso: repensando o sentido da prevenção. Physis. 2013;23(4):1189-213. https://doi.org/10.1590/S0103-73312013000400009
https://doi.org/10.1590/S0103-7331201300...
. A contemporary model focused on aging, but especially in the older adult, needs to gather a sequence of education, health promotion, prevention of evitable diseases and postponement of injuries. To achieve positive results, an articulated, referenced network with information system built is essential2424. Veras RP, Caldas CP, Cordeiro HA. Modelos de atenção á saúde do idoso: repensando o sentido da prevenção. Physis. 2013;23(4):1189-213. https://doi.org/10.1590/S0103-73312013000400009
https://doi.org/10.1590/S0103-7331201300...
, 3030. Veras RP, Caldas CP, Motta LB, Lima KC, et al. Integração e continuidade do cuidado em modelos de rede de atenção à saúde para idosos frágeis. Rev Saude Publica. 2014;48(2):357-65. https://doi.org/10.1590/S0034-8910.2014048004941
https://doi.org/10.1590/S0034-8910.20140...
.

CONCLUSIONS

The performance of comprehensive care for older adults in primary care services in the Brazilian Unified Health System in the state of São Paulo is incipient. Incipience is stronger in healthy aging care activities, while those for treatment of some chronic diseases show relatively better performance.

To distinguish three groups of decreasing performance services was possible according to the three domains evaluated. The intermediate group, group 2, concentrates most services (67%). The best group, group 1, is minority (12%). The worst performing group, group 3, concentrates 31 services (20%) and shows worst performance in all domains, especially in the healthy aging care.

Results indicate the need to improve older adults’ care in all domains, emphasizing, however, the urgency of improving local performance and health network in the effective implementation of actions to aging and older adults’ care according to the Ministry of Health guidelines. The precariousness of performance of various services also draws attention.

The evaluation framework was able to characterize and differentiate the current performance of older adults’ care in PHC services and can be used to establish and disseminate new normative standards for PHC.

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  • Funding

    Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), process 485848/2012-0. Doctorate scholarship for NP (2014-2018) by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

Publication Dates

  • Publication in this collection
    20 Jan 2020
  • Date of issue
    2020

History

  • Received
    01 Jan 2018
  • Accepted
    31 May 2019
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