Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults.
Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults.
复制标题
DOI：
10.1371/journal.pmed.1003357
复制
发表时间：
2020-10
期刊：
影响因子：
15.8
通讯作者：
Durovni B
中科院分区：
文献类型：
--
作者：
Hone T;Saraceni V;Medina Coeli C;Trajman A;Rasella D;Millett C;Durovni B
在许多低收入和中等收入国家，扩大向城市贫困人口提供初级保健是一个优先事项。尽管巴西在过去二十年中扩大了国际公认的家庭保健战略，但这仍然是巴西面临的一个主要挑战。这项研究评估了自2008年以来巴西里约热内卢市迅速扩大FHS覆盖范围的雄心勃勃的计划的影响。使用灵活的参数生存模型分析了1，241，351名低收入成年人（2010年1月至2016年12月观察;总人年6，498，607）与FHS使用和死亡记录相关的队列。估计FHS使用者和非使用者的全因和选定原因的死亡时间。模型采用逆概率治疗加权和回归调整（IPTW-RA）。该队列为61%的女性（751，895），平均年龄为36岁（标准差16.4）。只有18，721人（1.5%）受过高等教育，而102，899人（8%）没有受过正规教育。三分之二的人（827，250人; 67%）接受有条件的现金转移（Bolsa Família）。共分析了34，091例死亡，其中8，765例（26%）死于心血管疾病; 5，777例（17%）死于肿瘤; 5，683例（17%）死于外部原因; 3，152例（9%）死于呼吸系统疾病; 3，115例（9%）死于传染病和寄生虫病。三分之一的队列（467，155; 37.6%）使用FHS服务。在IPTW-RA生存分析中，与非FHS使用者相比，FHS使用者的全因死亡率平均降低44%（HR：0.56，95% CI 0.54-0.59，p < 0.001），5年风险降低8.3/1000（95% CI 7.8-8.9，p < 0.001）。黑人使用FHS的死亡风险降低更大（HR 0.50，95% CI 0.46-0.54，p < 0.001）或pardo（HR 0.57，95% CI 0.54-0.60，p < 0.001）与白色相比（HR 0.59，95%CI 0.56-0.63，p < 0.001）;教育程度较低（HR 0.50，95% CI 0.46-0.55，p < 0.001），与受过高等教育的人无显著相关性相比（p = 0.758）;或接受有条件现金转移（Bolsa Família）（HR 0.51，95% CI 0.49-0.54，p < 0.001）与未接受者（HR 0.63，95% CI 0.60-0.67，p < 0.001）相比。本研究的主要局限性是通过选择进入项目和连锁错误而产生的潜在未观察到的混杂，尽管分析方法已将偏倚的可能性降至最低。巴西城市贫困人口使用FHS与死亡风险降低有关，在更贫困的种族/族裔和社会经济群体中，死亡风险降低幅度更大。增加对初级保健的投资可能会改善全球城市贫困人口的健康状况，减少健康不平等。托马斯霍恩和他的同事探讨了家庭健康战略的初级卫生保健在低收入人群中的访问。主要来自高收入国家的证据表明，具有更强初级保健（PHC）的卫生系统具有更好的健康结果，减少健康不平等，并减少医疗保健费用的财务负担。然而，来自低收入和中等收入国家的证据往往存在方法上的缺陷，主要侧重于儿童和孕产妇健康，而不注重城市穷人等弱势群体，而且往往不按社会经济群体分列。自2008年以来，里约热内卢市大力扩大了初级保健服务，对电子病历进行了投资，为评估初级保健提供了宝贵的实验环境。里约热内卢市120万低收入成年人的行政福利记录与2010年至2016年期间的PHC记录和死亡证明相关联。PHC使用者的死亡风险与非使用者进行了比较，两组之间存在统计学校正差异。与非使用者相比，PHC使用者的死亡风险降低，但那些受教育程度较低、接受福利或黑人或帕尔多人（混合种族）的死亡风险降低最大。在低收入中等收入国家，初级保健的使用与低收入城市人口的健康效益有关，随着贫困社会经济群体的利益增加，有可能减少健康不平等。政策制定者应继续优先重视初级保健并对其进行投资，以此作为卫生系统加强努力和行动的一部分，推动实现全民健康覆盖。
Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country’s internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008. A cohort of 1,241,351 low-income adults (observed January 2010–December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54–0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8–8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46–0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54–0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56–0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46–0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49–0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60–0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias. FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally. Thomas Hone and colleagues explore the Family Health Strategy for primary health care access in a low-income population. There is evidence, predominantly from high-income countries, that health systems with stronger primary healthcare (PHC) have better health outcomes, reduced health inequalities, and reduced financial impoverishment from healthcare costs. However, evidence from low- and middle-income countries (LMICs) often has methodological weaknesses, focuses heavily on child and maternal health, does not focus on vulnerable groups such as the urban poor, and is not often disaggregated by socioeconomic groups. The city of Rio de Janeiro has undergone a major expansion of PHC services since 2008, with investments in electronic medical records that provide a valuable experimental setting for evaluating PHC. Administrative welfare records of 1.2 million low-income adults in the city of Rio de Janeiro were linked with PHC records and death certificates between 2010 and 2016. The risk of death for PHC users was compared with nonusers with statistical adjustment differences between groups. Compared with nonusers, PHC users had reduced risk of death, but those with lower education, receiving welfare, or who were black or pardo (mixed-ethnicity) had the greatest reductions. PHC usage is associated with health benefits in low-income urban populations in an LMIC and, with greater benefits in deprived socioeconomic groups, there is the potential to reduce health inequalities. Policymakers should continue to prioritize and invest in PHC as part of health system strengthening efforts and actions for progress toward Universal Health Coverage.
登录
查看更多内容
影响因子：
12.7
作者：
Guanais, Frederico C.
通讯作者：
Guanais, Frederico C.
影响因子：
4.8
作者：
de Azevedo Barros, Marilisa Berti;Lima, Margareth Guimaraes;Malta, Deborah Carvalho
通讯作者：
Malta, Deborah Carvalho
影响因子：
5.2
作者：
Marmot, M.;Bell, R.
通讯作者：
Bell, R.
DOI：
10.1590/1413-81232020256.19332018
发表时间：
2020-06-01
期刊：
Ciência & Saúde Coletiva
影响因子：
--
作者：
Mendonça, Carolina Siqueira;Machado, Dinair Ferreira;Castanheira, Elen Rose Lodeiro
通讯作者：
Castanheira, Elen Rose Lodeiro
影响因子：
15.8
作者：
Hone T;Rasella D;Barreto ML;Majeed A;Millett C
通讯作者：
Millett C