Analysis of factors associated with health care utilization and costs in the context of the Andersen model: a population-based study

Abstract

The decision-making process for planning and management of public policy of health has presented increasing challenges over the past decades, due to the complexity generated by the simultaneous occurrence of changes in age structure (demographic transition) and lifestyle (nutritional transition) of the population, which result in modifications in morbidity patterns of individuals (epidemiological transition) towards a higher prevalence of noncommunicable diseases (NCD). NCDs represent substantial social and economic impact for health systems and individuals, considering the direct and indirect costs involved in the treatment, recovery, productivity losses, and reduction in quality of life of patients. The existence of robust evidence regarding the factors associated with the utilization of health services by the local population favors improvements in the process of designing strategic actions aimed at disease prevention and health promotion. The theoretical approach of the Andersen's health services utilization model allows structuring the demand of health assistance based on the analysis of predisposing factors (sociocultural characteristics), enabling factors (logistical and economic characteristics), and need factors (health status) of individuals. However, there is lack of evidence on the factors associated with the demand for health care in Brazil based on the theoretical background of Andersen's model, especially considering studies with data representative at population level with data availability on multiple dimensions of individual's lifestyle (e.g., diet, physical activity, sedentarism, sleep quality, among others), in combination with psychological characteristics and data on biochemical and genetic diagnostic exams to assess individual's health status. Thus, the present project proposes to analyze the evolution and determinants of costs and use of health care in public and private sector in representative samples at the population level for the city of São Paulo and for Brazil, particularly among individuals exposed to cardiometabolic risk, through the theoretical approach of Andersen's model. The study comprises an observational analysis of cross-sectional data using quantitative analysis of data from the Sao Paulo Health Survey (Inquérito de Saúde de São Paulo, ISA-Capital) 2003, 2008 and 2015 and the Household Budget Survey (Pesquisa de Orçamentos Familiares, POF) 2002-2003, 2008-2009 and 2017-2018. Private health care costs (out-of-pocket) were declared by individuals interviewed in the survey editions. The costs of utilization of health care within the Brazilian Unified Health System (Sistema Único de Saúde, SUS), financed by the public sector, will be estimated using expenditures registered at DATASUS in the period of the surveys, considering type of health care, morbidity reported as a cause, and demographic characteristics of individuals. Multivariate linear and logistic regression models will be estimated for health care utilization and costs. Statistical analyses will be performed using the Stata software, considering the survey complex sampling procedures, based on two stage probabilistic sample, and a statistical significance level of 5% (p<0.05). The results will be interpreted using the structure of Andersen's model, seeking to propose strategies for proposition and assessment of public policies in health directed towards health promotion in the context of primary health care of the SUS and the supplementary private health system.