Avoidable hospitalizations in Brazil and Portugal: Identifying and comparing critical areas through spatial analysis

Background: Hospitalizations for ambulatory care sensitive conditions have been used to assess the performance of primary health care. Few studies have compared geographic variation in rates of avoidable hospitalizations and characteristics of high-risk areas within and between countries. The aim of this study was to identify and compare critical areas of avoidable hospitalizations in Brazil and Portugal, because these countries have reformed their primary health care systems in recent years and have similar organizational characteristics. Methods: An ecological study on hospitalizations for ambulatory care sensitive conditions produced in Brazil and Portugal in 2015 was used. Geographic variation of rates were analyzed and compared at the municipal level. A spatial scan statistic was employed to identify clusters with higher risk of hospitalizations for acute and chronic conditions in each country separately. Socioeconomic and primary health care characteristics of critical areas were compared to non-critical areas. Results: There were high variations in rates of avoidable hospitalizations within and between Brazil and Portugal, with higher variations found in Brazil. A more evident pattern of rates was found in Portugal. Rates and cluster distribution of acute and chronic conditions had significant agreement for both countries. The differences in primary health care and socioeconomic characteristics between areas identified as high risk clusters and non-clusters varied between category of conditions and between countries. Conclusion: Brazil and Portugal presented expressive regional differences with respect to rates of avoidable hospitalizations, indicating that there is room to improve by reducing such events in both countries. Different areas presented distinct interactions between primary health care, socioeconomic characteristics, and avoidable hospitalizations. Results indicate that the primary health care reforms, with similar organizational characteristics in different contexts, did not produce similar results either between or within countries. Possible actions to reduce these events should be defined at a local level.