Time Analysis of Hospital Costs for Respiratory Diseases in Brazil, 1998-2021

doi:10.21203/rs.3.rs-4987051/v1

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Research Article

Time Analysis of Hospital Costs for Respiratory Diseases in Brazil, 1998-2021

https://doi.org/10.21203/rs.3.rs-4987051/v1

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Background: Respiratory diseases (RD) affect individuals of all age groups, negatively impacting patients' quality of life and incurring significant costs to healthcare services. If not managed properly, they can also lead to mortality. Information provided by DATASUS on RD can be utilized to facilitate professional decision-making, set targets for approach and treatment, and support the creation of public policies aimed at this population.

Objective: To assess the financial costs of hospital admissions in the Brazilian population caused by respiratory diseases from 1998 to 2021.

Methods: This is a descriptive, longitudinal, and quantitative study, with data properly recorded in the Hospital Information System of the Unified Health System (SIH/SUS), regarding the costs generated by respiratory diseases in Brazil, including individuals aged 0 to 80 years. The data were analyzed using GraphPad Prism software version 5.0, and the significance level was set at 5%.

Results: A total of 34,749,023 hospital admissions were observed, representing a total cost of R$23,653,000,000.00 and an average cost of R$760.62 per hospital admission during the study period. The age group between 20 and 80 years showed the highest indices related to the number of admissions. Regarding the list of morbidities, pneumonia presented the highest costs to the public health system (R$11,415,000,000.00 - 48.3%). The Southeast region showed the highest financial support (R$9,192,000,000.00), the highest number of deaths (n= 907434 - 49%), and the highest average hospital stay (5.9 days).

Conclusion: Respiratory diseases, in addition to representing a public health problem, have a significant financial impact on the SUS. It is essential to prioritize strategy plans and actions to combat these diseases, especially pneumonia, targeting the male population and the Southeast region, aiming to reduce inequalities in public health.

hospital costs

respiratory diseases

pneumonia

According to the World Health Organization (WHO), respiratory diseases (RD) can affect structures in the upper airways, such as the nose, larynx, pharynx, and in the lower airways, such as the trachea, bronchi, bronchioles and alveoli. These structures are compromised by recurrent processes of inflammation, which can lead to airway interference and impaired respiratory function¹. Acute respiratory infections (ARIs), especially pneumonia, cause deaths in all age groups, being especially relevant in children in developing countries. However, according to the Forum of International Respiratory Societies, other RDs are prevalent in the population, such as tuberculosis, asthma, chronic obstructive pulmonary disease (COPD) and lung cancer, requiring attention from economic health authorities ^2–5.

RDs in Brazil are responsible for approximately 16% of all hospital admissions, 50% of which are due to pneumonia. In the pediatric population, RD covers more than 50% of hospitalizations^6,7. According to Vieira, Rizol and Nascimento⁷, they state in their study that, in 2012, there were around 1.3 million hospitalizations for respiratory diseases in Brazil, costing the Unified Health System (SUS) approximately US$6. billion.

Since its creation in 1988, the SUS has guaranteed full, universal and equal access for the population, from pregnancy to the end of life, covering both prevention and health promotion actions, as well as health assistance and care, as it is one of the largest public health systems in the world, covering the entire Brazilian population, estimated at 213 million inhabitants in 2021⁸. For decades, acute lower respiratory tract infections have been among the top three causes of death and disability among children and adults. Although difficult to quantify, around 4 million deaths occur each year and represent the leading cause of death among children under 5 years of age. Furthermore, respiratory tract infections, caused by influenza, for example, cause 250,000 to 500,000 deaths and cost between 71 and 167 billion dollars per year^9–11.

Hospital admissions due to RD have a negative impact on patients' quality of life and on the public health system. According to Cardoso¹², the average cost of a hospitalization in Brazil is approximately 160.00 USD (dollars), which currently corresponds, on average, to R$824.00 Reais. In general, hospital admissions cause a significant financial impact on the public health system, and studies that demonstrate these relationships are still scarce in Brazilian literature. Knowing these associations and their impacts can lead to better targeting of more effective actions by the competent bodies¹³. In this context, this study aims to evaluate the financial costs of hospital admissions in the Brazilian population caused by respiratory diseases between 1998 and 2021.

Characterization of the study

This is a cross-sectional, descriptive, longitudinal and quantitative study, with data duly recorded in the Hospital Information System of the Unified Health System (SIH/SUS), referring to the costs generated by respiratory diseases in Brazil, including individuals aged 0 to over than 80 years, which represents the entire Brazilian population. Hospital admissions from private or public services linked to the SUS from 1998 to 2021 were analyzed.

Ethical aspects

According to the guidelines of the National Health Council that regulates the National Research Ethics Commission (CONEP), Resolution No. 510 of April 7, 2016, ethical approval is not necessary. Therefore, all study data is public and freely accessible, and can be accessed at any time and free of charge through DATASUS (http://datasus.saude.gov.br/).

Data extraction

The variables analyzed were total value, average value, professional value, value of hospital services, average length of stay and deaths, correlating them with region, sex, age group and morbidity list, according to the ICD-10 referring to diseases of the respiratory system. The studied population consisted of diseases of the respiratory system - as defined by the International Classification of Diseases, 10th revision (ICD-10; J00-J99) - in which hospitalizations and deaths were reported between 1998 and 2021. For the geographic analysis, the variables were corrected by the population number in 2010, according to regions and states, through another database: the database of the Brazilian Institute of Geography and Statistics (IBGE), which provides data on the Brazilian population through censuses periodicals.

For the variables analyzed, the Epidemiology and Morbidity tables of the “SUS Hospital Morbidity” group were used and then the subitem “General, by place of hospitalization” using two available databases, the first from 1998 to 2007; and the second from 2008 to 2021. Regarding geographic coverage, “Brazil by region and federation unit” was defined. For the content, the following were inserted: “Admission”, “total value”, “average value” “hospitalization”, “average length of stay”, “days of stay”, “death”, “value of hospital services” and “value of professional services”.

All data analysis was carried out evaluating the general population, thus covering all ages available in DATASUS (zero to over 80 years old), and in two groups: Young Group aged zero to 19 years old; and the Adult Group (20 to over 80 years old).

Statistical analysis

Statistical analysis was performed using the GraphPad Prism Software program version 8.0 (San Diego, USA). Data normality was assessed using the Kolmogorov Smirnov test. Comparisons between regions and year were performed using the One-way ANOVA test with a Tukey post hoc or Kruskal-Wallis with Dunn's post hoc test. Comparisons between gender were analyzed using the unpaired Student t test or Mann-Whitney test. A value of p < 0.05 was considered statistical significance. Cost comparisons between the years 1998 vs. 2021 were adjusted by the values of the Broad National Consumer Price Index (NCPI) for the years 1998 and 2021, respectively, considering the country's inflation according to the IBGE. #IBGE - https://www.ibge.gov.br/explica/inflacao.php.

Costs related to the number of hospital admissions due to respiratory diseases (total value and average value)

34,749,023 hospitalizations resulting from RD were recorded in the Brazilian population, during the period from 1998 to 2021, representing a total of R$23,653,000,000.00 reais and an average of R$760.62 reais per hospitalization. For the age group aged less than 1 year to 19 years, designated in the analysis as the young group, the number of hospitalizations corresponded to 16,757,489.00 representing a total value of R$9,053,000,000.00 in the period studied, being an average of R$ 612.48 reais per hospitalization. And for the age group between 20 and over 80 years old, designated in the analysis as the adult group, 17,991,534 hospitalizations were observed, equivalent to R$14,610,000,000.00 reais, and an average of R$871.14 reais per hospitalization (p < 0.0001).

It was observed in the general population that 49.8% of hospital admissions n = 17,299,941 were due to pneumonia, followed by asthma, n = 5,161,825 − 14.9% and bronchitis/emphysema and other chronic obstructive pulmonary diseases n = 3,874 .542 − 11.2%. As for the total amount, expenses equivalent to R$11,415,000,000.00 were spent − 48.3% on hospitalizations for pneumonia; R$6,139,647,955.00–26% due to other diseases of the respiratory system; and R$ 2,303,278,197.00–9.7% for bronchitis, emphysema and other chronic obstructive pulmonary diseases, as shown in Table 1.

The total value data referring to hospital admissions according to the young group, were allocated to pneumonia R$5,056,659,617.00–55.9%; other diseases of the respiratory system R$1,470,595,724.00–16.2% and asthma R$1,238,601,886.00–13.7%. Regarding the adult group, data for pneumonia were R$6,358,136,064.00–43.5%; other diseases of the respiratory system R$4,667,200,207.00–31.9% and bronchitis/emphysema and other chronic obstructive pulmonary diseases R$2,158,036,529.00–14.8%, respectively.

The professional value analyzed, accordindifueg to Brazilian regions, presented costs equivalent to R$2,293,203,559.00 reais. Regarding the list of morbidities, in the general population, pneumonia R$1,077,220,216.00–47%, other diseases of the respiratory system, R$736,478,427.80–32.1%, and chronic diseases of the tonsils and adenoids, R$139,050,136.90–6.1%, obtained higher financial indexes, respectively, represented in Table 1.

When comparing total costs, the group known as adults, over 20 years of age to 80 years or more, is responsible for the highest expenditure on respiratory diseases (p < 0.005) when compared to the group aged up to 19 years. For this age group, defined as the young group, we can highlight higher numbers of hospitalizations for acute pharyngitis and tonsillitis, laryngitis and tracheitis, acute bronchitis and bronchiolitis, chronic diseases of the tonsils and adenoids, asthma (p < 0.001) and other acute infections of upper airways (p < 0.005). The costs, with total, average and professional value when compared to the groups, are shown in Table 1.

Table 1

Distribution of hospital admissions according to the list of morbidity, total value, average value and professional value of the ICD-10 for diseases of the respiratory system, Brazil, 1998–2021. Data from the general population (less than 1 to 80 years or more), the young group (less than 1 year to 19 years) and the adult group (20 and > 80 years).
Distribution of hospital admissions
Respiratory diseases Young Group vs. Adult Group	No. of hospitalizations (%)	Amount	Average value	Professional Value
Acute pharyngitis and acute tonsillitis < 1–80 < 1–19 20->80	152167 (0.4) 104111 (0, 6)* 48056 (0.3)	R$ 43,334,215.30 R$ 29,633,958.60* R$ 13,700,259.55	BRL 251.67 BRL 251.31 BRL 252.18	BRL 5,267,770.91 R$ 3,574,921.82 R$ 1,692,849.09
Acute laryngitis and tracheitis < 1–80 < 1–19 20->80	706645 (2.0) 468765 (2, 8)* 237880 (1.3)	R$ 126,929,656.00 R$ 85,122,702.00* R$ 41,806,953.10	R$ 214.25 R$ 216.02 BRL 209.79	BRL 7,350,305.96 R$ 5,090,084.97* BRL 2,260,220.99
Other acute upper respiratory infections < 1–80 < 1–19 20->80	360915 (1.0) 228575 (1, 4)# 132340 (0.7)	R$ 109,409,623.00 R$ 54,216,409.10 R$ 55,193,213.20	R$ 316.33 R$ 226.87 BRL 435.11	R$ 11,465,160.23 R$ 6,119,252.12 R$ 5,345,908.11
Influenza [flu] < 1–80 < 1–19 20->80	692751 (2.0) 362318 (2.2) 330433 (1.8)	R$ 424,220,403.00 R$ 199,828,338.40 R$ 224,392,064.60	BRL 613.27 BRL 570.78 BRL 621.91	R$ 36,619,195.90 R$ 13,217,424.59 R$ 23,401,771.31*
Pneumonia < 1–80 < 1–19 20->80	17299941 (49.8) 9008490 (53.8) 8291451 (46.1)	R$ 11,415,000,000.00 BRL 5,056,659,617.00 R$ 6,358,136,064.00	BRL 723.93 BRL 652.13 BRL 762.02	R$ 1,077,220,216.00 R$ 411,469,010.80 R$ 665,751,205.00#
Acute bronchitis and acute bronchiolitis < 1–80 < 1–19 20->80	1090529 (3.1) 971,947.00 (5, 8)* 118582 (0.7)	R$ 340,576,880.00 R$ 303,259,275.00* R$ 37,317,603.80	R$ 298.44 R$ 296.18 R$ 291.83	R$ 35,816,105.72 R$ 31,952,574.91* R$ 3,863,530.81
Chronic sinusitis < 1–80 < 1–19 20->80	48366 (0.1) 9541 (0.1) 38825 (0, 2)*	R$ 25,098,419.30 R$ 4,669,805.19 R$ 20,428,613.10*	R$ 480.40 BRL 499.13 BRL 476.93	R$ 8,058,088.58 R$ 1,391,533.54 R$ 6,666,555.04*
Other diseases of the nose and paranasal sinuses < 1–80 < 1–19 20->80	354721 (1.0) 100709 (0.6) 254012 (1.4)	R$ 149,249,858.00 R$ 44,549,744.30 R$ 104,700,115.00	BRL 389.17 BRL 413.37 R$ 379.30	R$ 46,649,520.78 R$ 13,871,563.10 R$ 32,777,957.68#
Chronic diseases of the tonsils and adenoids < 1–80 < 1–19 20->80	1035411 (3.0) 939248 (5, 6)* 96163 (0.5)	R$ 380,586,314.00 R$ 345,353,122.00* R$ 35,233,191.80	BRL 349.35 BRL 350.46 BRL 337.27	R$ 139,050,136.90 R$ 126,178,727.80* R$ 12,871,409.07
Other upper respiratory tract diseases < 1–80 < 1–19 20->80	527603 (1.5) 279423 (1.7) 248180 (1.4)	R$ 163,200,934.00 R$ 62,899,110.00 R$ 100,301,827.00*	BRL 384.08 R$ 259.94 BRL 482.53	R$ 19,730,356.58 R$ 5,826,422.91 R$ 13,903,933.67#
Bronchitis, emphysema and other chronic obstructive pulmonary diseases < 1–80 < 1–19 20->80	3874542 ((11.2) 219978 (1.3) 3654564 (20, 3)*	R$ 2,303,278,197.00 R$ 146,376,727.40 R$ 2,158,036,529.00*	BRL 672.97 BRL 618.97 BRL 683.26	R$ 109,554,371.30 R$ 11,524,462.17 R$ 98,029,909.17*
Asthma < 1–80 < 1–19 20->80	5161825 (14.9) 320808500 (19, 1)* 1953740 (10.9)	R$ 1,984,801,084.00 R$ 1,238,601,886.00* R$ 745,660,810.00	BRL 451.25 BRL 448.65 BRL 456.78	R$ 55,302,806.33 R$ 34,031,225.51* R$ 21,271,580.82
Bronchiectasis < 1–80 < 1–19 20->80	64021 (0.2) 14287 (0.1) 49734 (0.3)	R$ 48,332,851.00 R$ 10,575,210.30 R$ 37,757,639.40#	BRL 985.34 BRL 942.58 R$ 1,003.76	R$ 3,800,380.24 R$ 902,440.26 R$ 2,897,939.98#
Pneumoconiosis < 1–80 < 1–19 20->80	13251 (0.0) 1312 (0.0) 11939 (0.1)	R$ 10,625,944.90 R$ 910,137.83 R$ 9,715,807.00*	BRL 806.4 BRL 818.07 BRL 814.63	R$ 840,715.90 R$ 80,023.91 R$ 760,691.99*
Other diseases of the respiratory system < 1–80 < 1–19 20->80	3366335 (9.7) 840700 (5.0) 2525635 (14, 0)*	R$ 6,139,647,955.00 R$ 1,470,595,724.00 R$ 4,667,200,207.00*	R$ 1,895.70 R$ 2,111.87 R$ 1,846.24	R$ 736,478,427.80 R$ 164,175,325.70 R$ 572,303,102.10#
Total < 1–80 < 1–19 20->80	34749023 16757489 17991534	R$ 23,653,000,000.00 R$ 9,053,000,000.00 R$ 14,610,000,000.00	BRL 760.62 BRL 612.48 BRL 871.14	R$ 2,293,203,559.00 R$ 829,404,994.10 R$ 1,463,798,565.00#

Source: Ministry of Health - SUS Hospital Information System (SIH/SUS).

* p < 0.0001, #p < 0.005, Unpaired Student t Test (Young Group vs. Adult Group).

Costs related to the number of hospital admissions for respiratory diseases by region of Brazil (total and average values)

Regarding the longitudinal variation between 1998 and 2021 in hospital costs according to the regions of the country, in the general population there was a significant statistical difference between them, p < 0.0001, showing an increase over the years, demonstrating greater financial support for the Southeast region. It was observed that, from 2008 onwards, there was an increase in this financial contribution to the regions, so that the Southeast region R$9,192,000,000.00–38.9%, the Northeast R$5,782,000,000.00–24.4% and South R$ 5,156,000,000.00–21.8% had higher costs in relation to the total value (Fig. 1 - a), respectively, allocated to respiratory diseases in Brazil during the period analyzed.

When we analyze the total value of costs in the young group, we observe that the Southeast regions R$3,161,293,509.00–36.2%, Northeast R$ 2,623,516,084.00–29% and South R$ 1,541,554,378.00–17%, presented the highest costs, respectively, p < 0.0001 (Fig. 1 - b). For the adult group, costs behaved differently, with the Southeast R$ 5,794,560,808.00–3.7%, the South R$ 3,613,504,931.00–24.7% and the Northeast R$ 3,161,293,509. 00–21.6%, the highest values, respectively, p < 0.0001 (Fig. 1- c).

Figure 1. Temporal analysis of hospital costs according to Brazilian regions due to respiratory diseases between 1998 and 2021. a) general population (p < 0.0001); b) young group (p < 0.0001) and c) adult group (p < 0.0001). Source: Ministry of Health - SUS Hospital Information System (SIH/SUS).

These numbers seem encouraging, however, when we correct the values using the Broad National Consumer Price Index (NCPI), made available by the Brazilian Institute of Geography and Statistics, (IBGE – Brazil), for the respective years of 1998 and 2021, we see a growing discrepancy between what should have been spent and what actually was. Table 2 shows the values corrected for inflation in the years compared.

Table 2

Comparative analysis of hospital costs according to Brazilian regions due to respiratory diseases between 1998 and 2021.

Source: Ministry of Health - SUS Hospital Information System (SIH/SUS).
Region	1998 Amounts spent	2021 Amounts spent	Amounts corrected by inflation
< 1–80 years
North	R$ 27.699.737,00	R$ 73.220.785,00	R$ 231.924.580,99
Northeast	R$ 136.000.000,00	R$ 256.000.000,00	R$ 1.138.701.895,06
Southeast	R$ 181.000.000,00	R$ 508.00.000,00	R$ 1.515.478.257,40
South	R$ 130.000.000,00	R$ 273.000.000,00	R$ 1.088.465.046,75
Midwest	R$ 41.892.896,00	R$ 85.069.287,00	R$ 350.761.176,95
< 1–19 years
North	R$ 15.916.358,00	R$ 28.538.041,00	R$ 133.264.610,42
Northeast	R$ 77.119.382,00	R$ 68.147.689,00	R$ 645.705.782,57
Southeast	R$ 83.961.256,00	R$ 113.000.000,00	R$ 702.991.480,29
South	R$ 52.004.416,00	R$ 42.462.503,00	R$ 435.422.993,02
Midwest	R$ 20.390.862,00	R$ 17.500.350,00	R$ 170.728.773,54
20->80 years
North	R$ 11.783.379,00	R$ 44.682.744,00	R$ 98.659.970,57
Northeast	R$ 58.619.108,00	R$ 188.000.000,00	R$ 490.806.539,46
Southeast	R$ 96.560.808,00	R$ 395.000.000,00	R$ 808.485.110,72
South	R$ 78.014.580,00	R$ 230.000.000,00	R$ 653.201.103,59
Midwest	R$ 21.502.034,00	R$ 67.568.937,00	R$ 180.032.403,41

Regarding the average value of hospital admissions due to RD, during the period evaluated, an average of R$760.00 per admission was observed, and there was no statistically significant difference between the regions (p = 0.1416). An increase of 82.74% was observed, R$1,277.71 reais, when comparing the average hospitalization between 1998 R$266.64 reais and 2021, R$1,544.35 reais, p < 0.0001. However, when corrected for the country's inflation, the value should be R$ 2,232.53 reais.

When comparing the regions, a significant increase was observed in the average value of hospital admission in all regions, with the greatest increase in the South region of 566% (1998 - R$ 295.6 and 2021 - R$ 1970.47), Southeast 461% (1998 - R$ 288.13 and in 2021 R$ 1617.56), and Central-West 602% (1998 - R$ 256.93 and in 2021 R$ 1548.71) when compared between 1998 and 2021.

Evaluating the young group, the average cost of hospitalization was R$612.48 per hospitalization and there was no statistically significant difference between the regions (p = 0.2960). However, behavior over the years showed that the regions that suffered the greatest average increases were: Southeast 408% (1998 - R$ 264.97 and in 2021 R$ 1082.18), South 401% (1998 - R$ 276.06 and R$1107.87), and Central-West 248% (1998 - R$250.76 and in 2021 R$873.23).

In the adult group, the average value is R$871.14, higher than the average value for the general population, but there was no statistically significant difference between the regions (p = 0.2277). However, regions observed with the greatest increases were: Southeast 504% (1998 - R$311.84 and in 2021 R$1,885.04), South 641% (1998 - R$310.23 and in 2021 R$2,301.03) and Midwest 636% (1998 - R$263.07 and in 2021 R$1,936.74).

Although some values have increased significantly, these do not follow the values corrected for inflation in the country, as shown in Fig. 2.

Figure 2. Temporal analysis of the average values and corrected values (by inflation) of hospitalizations according to Brazilian regions for respiratory diseases between 1998 and 2021. a) general population; b) youth group and c) adult group. Source: Ministry of Health - SUS Hospital Information System (SIH/SUS).

Costs related to the number of hospital admissions for respiratory diseases by sex (total value, average value and professional value)

In the general population, a total amount of R$23,653,000,000.00 was allocated to the sexes, so that males spent the most, R$12,822,000,000.00; 54.2%, compared to females, R$ 10,841,000,000.00; 45.8%. However, there was no statistically significant difference between them, p = 0.0508.

When analyzing the age groups, it was observed that in the male, young and adult groups the total amount allocated was distributed as follows: R$5,021,000,000.00 and R$7,800,000,000.00, respectively, while in the female sex, in the youth group the amount of R$4,032,000,000.00 was spent, while for the adult group it was R$6,810,000,000.00.

Regarding the average value of hospital admissions for RD considering the sexes, during the period evaluated, these presented costs of R$735.32 for females and R$783.29 for males, however there was no statistically significant difference, p = 0. 5028 when compared. When adjusted for inflation, the values for the year 2021 should be R$ 2,293.53 for males and R$ 2,167.39 for females. For the young group, males presented an average value of R$ 616.62, and for females R$ 607.38 reais. When adjusted for inflation, the values for the year 2021 should be R$ 2,126.86 for males and R$2,069.17 for male. For the adult group, for males R$ 919.41 and for females R$ 821.51 reais. When adjusted for inflation, the values for the year 2021 should be R$ 2,491.25 for male and R$ 2,259.57 for females. Males had a higher average value spent when compared to females, but there was no statistically significant difference between them (p = 0.7337, p = 0.3809, respectively).

Analysis of deaths from respiratory diseases related to region, age group, sex and morbidity list

1,852,271 deaths due to hospitalizations for respiratory diseases were observed in the general population between 1998 and 2021, with a significant difference being recorded between regions p < 0.0001. The Southeast region had the highest incidence of deaths 49% (n = 907434), followed by the South region 20.9% (n = 386941) and the Northeast region 19.5% (n = 361057), respectively. The age groups with the highest mortality rates in the general population are over 80 years old (31%); 70–79 years old (24%); 60–69 years (17.1%), respectively.

Of the deaths observed in the general population, 54.3%, n = 1006441 were male and 45.7%, n = 845830 were female (p = 0.0049). At the young age group, for males, 54.6%, n = 56167 deaths were recorded and for females 45.4%, n = 46610, showing no statistically significant difference between the sexes, p = 0.0526. For the adult age group, males had more deaths, 54.3%, n = 950274 than females 45.7%, n = 799220, with a statistically significant difference p = 0.0091. Both age groups follow the trend of the population in general.

Regarding the list of morbidities, 49.5%, n = 917338 deaths resulting from pneumonia were observed in the general population, followed by other diseases of the respiratory system 35.6%, n = 659327, and bronchitis/emphysema and other chronic obstructive pulmonary diseases 11.5%, n = 213450, respectively. At the young age group, two ICDs together account for approximately 100% of deaths, they are: pneumonia 48%, n = 4301 and other diseases of the respiratory system 45.1%, n = 46356. For the adult age group, we observed the following behavior: most deaths are caused by pneumonia 49.6%, n = 868037, followed by other diseases of the respiratory system 35%, n = 612971 and bronchitis/emphysema and other lung diseases chronic obstructive 12.2%, n = 212814.

Analysis of the average hospital stay for respiratory diseases related to region, age group, sex and morbidity list

The inferential analysis regarding the average length of hospital stay by region shows a statistically significant difference between regions, p < 0.0001. When looking at the average hospital stay of the general population during the period evaluated, the Southeast and South regions presented 5.9 and 5.2 days, respectively. While the Northeast and Central-West regions were equivalent with 4.8 days and, finally, the North region had an average length of stay of 4.6 days. This pattern was identified for the other young and adult age groups (Fig. 3).

Figure 3. Temporal analysis of the average hospital stay according to Brazilian regions due to respiratory diseases between 1998 and 2021. a) general population (p < 0.0001); b) young group (p < 0.0001) and c) adult group (p < 0.0001). Source: Ministry of Health - SUS Hospital Information System (SIH/SUS).

The highest rates of average days of stay evaluating the days of hospital stay were found in the age groups 60 to 69 years − 6.4; 70 to 79 years old − 6.4; 80 years and over − 6.4 demonstrating higher averages p < 0.0001.

According to ICD-10, the three main diseases for which patients remain hospitalized for the most days were: pneumoconiosis with an average of 8.9; other diseases of the respiratory system 8.6 and bronchiectasis 8.4, respectively, shown in Table 3.

Table 3

Distribution of average and days of hospital stay according to the ICD-10 morbidity list for respiratory system diseases, Brazil, 1998–2021. Including data from the general population (less than 1 to 80 years or more), the young group (less than 1 year to 19 years) and the adult group (20 and > 80 years).
Respiratory diseases Young Group vs. Adult Group	Average permanence hospital	Days of stay hospital
Acute pharyngitis and acute tonsillitis < 1–80 < 1–19 20->80	54.2 67.0 73.5	2.9 2.8 3.0
Laryngitis and tracheitis high-pitched < 1–80 < 1–19 20->80	58.2 72.2 78.7	3.2 3.1 3.4
Other acute upper airway infections < 1–80 < 1–19 20->80	67.4 73.9 101.5	3.3 2.9 4.0
Influenza [flu] < 1–80 < 1–19 20->80	87.1 103.1 115.9	4.8 4.7 5.0
Pneumonia < 1–80 < 1–19 20->80	108.6 123.0 151.1	5.7 5.1 6.3
Acute bronchitis and acute bronchiolitis < 1–80 < 1–19 20->80	78.0 98.9 90.7	4.1 4.1 4.1
Sinusitis chronicle < 1–80 < 1–19 20->80	44.5 61.5 55.4	2.3 2.6 2.2
Other diseases of the nose and paranasal sinuses < 1–80 < 1–19 20->80	24.9 29.0 32.5	1.2 1.2 1.3
Chronic diseases of the tonsils and adenoids < 1–80 < 1–19 20->80	17.3 21.6 27.5	0.9 0.9 1.1
Other upper respiratory tract diseases < 1–80 < 1–19 20->80	61.8 74.3 83.2	3.2 3.1 3.4
Bronchitis, emphysema and other chronic obstructive pulmonary diseases < 1–80 < 1–19 20->80	112.7 179.0 147.5	5.9 4.3 6.0
Asthma < 1–80 < 1–19 20->80	58.5 71.1 80.2	3.1 3.0 3.4
Bronchiectasis < 1–80 < 1–19 20->80	159.9 149.7 221.5	8.4 5.9 9.1
Pneumoconiosis < 1–80 < 1–19 20->80	169.2 155.4 221.9	8.9 6.5 9.1
Other diseases of the respiratory system < 1–80 < 1–19 20->80	163.8 218.7 206.3	8.6 8.7 8.6

Source: Ministry of Health - SUS Hospital Information System (SIH/SUS).

p > 0.05, Unpaired Student t Test (Young Group vs. Adult Group).

In the analysis by sex in relation to the average hospital stay, in the general population, males had an average of 5.4 days of stay, and females had an average of 5.1 days, with a statistically significant difference, p = 0. 0085. In both groups, the average length of stay behaves similarly; in the young group, males had 4.4 and females had 4.4. In the adult group, for males 6.4 and for females 5.7 days.

Thus, the behavior is the same as the overall age group, so that males have a higher average hospital stay when compared to females, but only the adult group presents statistical differences with p = 0.0001, while for the young group, p = 0.2113, there was no statistical difference.

Among the main findings of the present study, the following stand out: 34,749,023 hospitalizations resulting from RD were recorded, representing a total of R$23,653,000,000.00 reais and an average of R$760.62 reais per hospital admission. The age group between 20 and 80 years old presented higher rates related to the number of hospitalizations, total amount allocated, and average value of hospital stay. When analyzing the list of morbidities, for the age groups studied, pneumonia presented greater costs to the public health system. Regarding hospital costs related to the total value according to regions, the greatest financial support was spent on the Southeast region. The mortality analysis shows that the Southeast region had a higher incidence of deaths, with males presenting higher mortality, regardless of age group. The Southeast region also stood out in terms of the average hospital stay for the general population, with 5.9 days. And when specifying the ages, the highest rates of average days of stay evaluating the days of hospital stay were found in the age groups 60 to 69 years old − 6.4 days; 70 to 79 years old − 6.4 days; 80 years and over − 6.4 days.

In the present study, among the RD analyzed, pneumonia was the costliest disease for health services, being present in both the young and adult populations, and this reality extends beyond the Brazilian reality. Kaier and his collaborators14 analyzed clinical data collected from a German university hospital with 2,000 beds, during the period 2011 and 2014. In the analysis, 204,914 complete patient records were evaluated, evaluating information on age, sex, main and secondary diagnoses and cost values calculated according to the standardized costing system developed by the Institute for the Hospital Remuneration System (InEK). They identified that both hospitalizations with a primary and secondary diagnosis of pneumonia represented high financial rates, around 14 thousand euros, in this single center.

The Global Burden of Disease (2015) Study was developed to carry out a temporal analysis in 195 countries and territories, between 1980 and 2015, to highlight the causes of mortality in the studied population. In 2015, pneumococcal pneumonia was the main cause of deaths of children under 5 years of age due to lower respiratory infections (393,000 deaths), but it also identified that the pathogen may vary according to region¹⁵.

A retrospective observational cohort study carried out on 74 patients discharged between January 2004 and July 2005, diagnosed with ventilator-associated pneumonia (VAP), indicates that approximately five to ten cases per 1,000 hospital admissions. Furthermore, patients who developed nosocomial pneumonia had longer lengths of stay, approximately 1.6 times the length of stay, which resulted in a large financial loss, being 1.7 times greater than patients who did not develop ventilation-associated pneumonia¹⁶.

Other diseases also generated high financial costs for health services, such as COPD, which represents the third leading cause of mortality in the United States, resulting in a cost of US$32 billion in direct annual investments. Furthermore, frequent exacerbations reduce health-related quality of life, increase morbidity and mortality and influence the socioeconomic area. In 2010, the Centers for Medicare and Medicaid - CMS implemented the Hospital Readmission Reduction Program (HRRP) and identified that it could reduce approximately US$17 billion in unnecessary hospital readmission expenses¹⁷.

Another result worth highlighting regarding COPD was found in the study by Lykkegaard and collaborators18 showing that at least 60% of all patients treated for COPD in Denmark were never treated in specialized pulmonology care. This research also showed that the average total individual cost of healthcare for a patient who received specialized treatment for COPD is between 2.19 and 2.58 times higher than that of a patient who was only treated for COPD in a general clinic. In turn, in the European Union, it is estimated that COPD represents around 56% (38.6 billion euros) of the costs allocated to RD¹⁹.

Kaur and her collaborators²⁰ showed in their study that asthma is responsible for more than 15 million medical and outpatient hospital visits, and almost 2 million emergency room visits each year. According to data from the Centers for Disease Control and Prevention's National Asthma Control Program, the proportion of people with asthma in the U.S. has grown by nearly 15% over the past decade. In 2009, there were approximately 24.6 million asthma patients, resulting in 479,300 hospitalizations.

A study carried out in Iran evaluated the estimated cost of hospitalization of an asthmatic patient, and based on its results, outpatients represented 85.5% of the total direct costs of asthma, and children had the highest management costs. of the disease. However, in this research, outpatient costs were higher than hospital admission costs²¹.

Analyzing differences between genders, the highest cost rates were attributed to the male population. Therefore, it is necessary to consider the cultural aspects of our society, in which women have a greater habit of seeking health services, investing in prevention and self-care when compared to men. Thus, over the years, there has been an increase in the number of diseases among men and, when diagnosed, they present themselves at a more advanced stage, requiring specialized support and, therefore, represent a greater cost to health services. in Brazil²².

In general, the male public only seeks medical care when they are affected by a serious illness, some refer to health spaces as an environment more focused on women's health. Another barrier to accessing the service concerns the incompatibility of working hours, which makes access difficult. Therefore, the inclusion of this population in health programs is a public health problem²³. With the failure in prevention and health promotion, the need of this public is directed towards higher levels of complexity of care, which may justify the finding of our study that shows that the average hospital stay for men was higher when compared to the average of women's hospital stay. When observing Brazilian regions, inequalities can be seen through the territorial configuration of the Unified Health System (SUS).

In this aspect, the results found in the present study show that the Southeast region has higher rates of costs related to hospital admissions, in this analysis focused on respiratory diseases. And finally, a study carried out at Prince Hamzah Hospital, located in Jordan, during 2007, identified 19,218 hospital admissions, with an average of 4.5 days, representing a total cost of US$16.8. The average cost per hospitalization of critically ill patients was the highest, such as patients in the Pediatric Intensive Care Unit - PICU²⁴.

The present study has some limitations, since it involves the use of secondary data through DATASUS, which is considered an official database of the federal government, which may be affected by the lack of some data on the platform or storage failures, since the time period chosen for the analysis was extensive.

Considering Brazil as a developing country, with limited financial resources aimed at the health of the population and, thinking strategically about health actions aimed at the financial impact of respiratory diseases on health services and government actions, this research updates the spending panorama by region, gender and age group for respiratory diseases in Brazil, bringing specialized attention to resolving these issues.

The analysis makes it possible to reflect on the impact of the disease on the health of the Brazilian population, especially those in the older age group. Such findings contribute information that allows better control and monitoring of respiratory diseases and should be taken into consideration when implementing new strategies for prevention, assistance and control of risk factors for the development of these diseases.

The importance of prioritizing strategy plans and actions to combat these diseases, especially pneumonia, for men and in the Southeast region is highlighted, aiming to reduce inequalities in public health. Effective health promotion, prevention and care measures must be intensified in order to improve the management of the treatment of these diseases and, consequently, promote the reduction of financial costs and/or better distribution of these.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests

The authors declare that they have no competing interests.

Funding

This study was partly financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES). Finance Code 001.

Authors' contributions

MLBAS, LGA, JPSS, INDFL contributed with conception, design of study, the acquisition, analysis, interpretation of data and have drafted the work; SGBN, LPG, INDFL substantively revised it and to have approved the submitted version.

Acknowledgements

Not applicable

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Time Analysis of Hospital Costs for Respiratory Diseases in Brazil, 1998-2021

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Abstract

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INTRODUCTION

METHODS

Characterization of the study

Ethical aspects

Data extraction

Statistical analysis

RESULTS

Analysis of deaths from respiratory diseases related to region, age group, sex and morbidity list

DISCUSSION

CONCLUSIONS

Declarations

References

Additional Declarations

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Version 1