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Enfermería Global
versión On-line ISSN 1695-6141
Enferm. glob. vol.21 no.65 Murcia ene. 2022 Epub 28-Mar-2022
https://dx.doi.org/10.6018/eglobal.444591
Reviews
Quality of health care for the elderly in primary care: an integrative review
1 Escuela de Salud y Medicina, Programa de Posgraduación en Gerontología. Universidad Católica de Brasilia (UCB). Brasília-DF, Brasil. saraivaaguiarricardo@gmail.com
Objective:
To investigate, through an integrative literature review, the quality of health care for the elderly in primary care.
Material and Methods:
Integrative literature review conducted in MEDLINE/PubMed, SciELO, LILACS and BDENF databases between April and May 2020, which generated 780 references. After removal of the duplicates and use of inclusion and exclusion criteria, the final sample consisted of 15 articles.
Results:
The quality of health care for the elderly in primary care was associated with potential and weaknesses that involved the availability and training of human resources, adoption of evaluation protocols, monitoring and follow-up, supply of inputs and structural variables linked to infrastructure and intersectoral support network. The effectiveness of actions to the elderly in primary care was related to the implementation of the Family Health Strategy, combined with the active action of the community health agent in the territory and the participation of the elderly in the decisions.
Conclusion:
Strengthening the health care of the elderly in primary care involves short, medium and long-term efforts related to education, human and material resources management, networking, and the formation of ties with the territory and the elderly person.
Keywords: Health of the Elderly; Primary Health Care; Quality of Health Care
INTRODUCTION
The aging population has been the agenda of managers, professionals, academics and public policy makers in order to ensure that old age is well assisted and cared for. In the field of gerontological care, it becomes necessary to plan and implement resolute and quality services that offer social responses to the challenges imposed by the increase of longevity elderly1, with functional limitations, chronic non-communicable diseases (NCD), greater risk of fragility and adverse health outcomes2.
For this, one of the bets of the health care models has been the adoption of long-term care combined with Primary Health Care (PHC) and anchored by an integral and comprehensive view of the elderly person, their resources and predisposing conditions of the health process and disease3.
In Brazil, efforts have been undertaken in the Brazilian Unified Health System (UHS) with the objective of reorganizing the care practice and health of the elderly. The PHC is defined by the National Policy on Health of the Elderly (NPHE) as the gateway to health care for the elderly and the reference for the network of specialized services of medium and high complexity4. Later, the National Primary Care Policy (NPCP) establishes actions such as health promotion and protection, prevention of illness, diagnosis, treatment, rehabilitation and maintenance of health5.
The NPHE deliberates relevant guidelines for comprehensive health care for the elderly, such as the promotion of healthy and active aging, support for the development of informal care, as well as rehabilitation and maintenance of functional capacity being responsible for guiding all actions in the health sector and indicating the responsibilities of institutions to achieve the proposal. In addition, it guides on the continuous process of evaluation that must accompany its development, taking into account possible adjustments coming from the practice. Its implementation includes the definition and/or readjustment of projects, programs, plans and activities in the health sector directly or indirectly related to its object6,7.
According to research conducted in Brazil, the implementation of care for the elderly in the context of PHC includes as challenges the lack of integrality of actions, the defragmentation of care, the absence of interprofessional teams and difficulties in using and accessing the health system8. Data from the Brazilian ELSI study indicated that the population aged 50 years or older and attending the traditional Basic Health Units (BHU) had a higher prevalence of access difficulties, continuity of care, communication with the medical professional, coordination and resolution of care when compared to the population assisted by the Family Health Strategy (FHS) and users of the supplementary health system9.
In this sense, investigating the factors that enhance and weaken the quality of care for the elderly in PHC can help professionals and managers to act in the planning and improvement of care offers. This theme is of great relevance, because 75.3% of the Brazilian elderly depend exclusively on the UHS to have access to health services and 70% have one or more CNCD. Of the services accessed by this population, 83.1% made at least one medical consultation in the last 12 months and 10.2% of the elderly were hospitalized one or more times9.
Therefore, the objective of the present study was to investigate, through an integrative review of the literature, the quality of health care for the elderly in primary care.
MATERIAL AND METHODS
This is an integrative review of the literature carried out in seven stages10: 1) delimitation of the guiding question for the review, 2) definition of inclusion and exclusion criteria, 3) extensive search of the literature, 4) identification of potential studies through evaluation of the title and abstract, 5) selection of articles based on the full text, 6) evaluation of the quality of the studies included, and 7) synthesis of the studies included.
In view of the first phase of the review, the research guiding question was elaborated based on the PICO strategy: P - population and problem, I - intervention, C - comparison and O - outcome. Thus, we considered P: elderly users in PHC, I: quality of care, C: any comparison regarding the factors related to the quality of care for the elderly and O: health care. In this direction, the question was: what are the potential and fragility factors for the quality of care of the elderly in PHC?
The search for the articles was conducted between April and May 2020 in the electronic databases MEDLINE/PubMed, Scientific Electronic Library Online (SciELO), Scientific and Technical Literature of Latin America and the Caribbean (LILACS) and Nursing Database (BDENF).
In order to define the search terms, the Health Sciences Descriptors (DeCS) were consulted. The descriptor "health of the elderly" and its correlates were chosen and combined with the search term "primary health care" and "quality of health care" and their respective expressions in English. The Boolean operators "AND" and "OR" were used for combination. The strategies constructed with the search terms and their results are presented in Box 1.
Chart 1: Search strategies and results of identified productions. Brasília, Distrito Federal, 2020.
![](/img/revistas/eg/v21n65//1695-6141-eg-21-65-545-gt4.png)
Elaboration: Aguiar RS, Silva HS, 2020.
The inclusion criteria for the sample were: studies with people aged 60 years or older, health professionals and managers; studies addressing the quality of care for the elderly in PHC; studies with qualitative, quantitative and mixed methods design; articles published online in the last 5 years (2015 to 2020), available in Portuguese, English or Spanish and in full. Literature reviews, congress abstracts, proceedings, editorials, dissertations and theses were discarded.
The database search generated 780 references. The selection of studies was conducted by exporting the results of searches in the electronic databases to the EndNote desktop® reference manager. With the program, 69 duplicates were removed and 453 in the temporality (last 5 years), which resulted in 258 for evaluation of other inclusion criteria through the reading of titles and abstracts. Of these, 228 were excluded depending on the theme (n= 172), method (n=30), not having an abstract (n=15) or being a dissertation and thesis (n=11). At the end, 30 articles presented potential for inclusion in the sample and, among these, 15 were chosen after full reading (Figure 1).
![](/img/revistas/eg/v21n65//1695-6141-eg-21-65-545-gf2.png)
Figure 1: Database search flowChart according to PRISMA recommendations. Brasília, Distrito Federal, 2020.
The evidence for the articles was classified into six levels: Level I - studies related to the meta-analysis of multiple controlled studies; Level II - individual experimental studies; Level III - quasi-experimental studies, such as the non-randomized clinical trial, the single group pre- and post-test, in addition to time series or case-control; Level IV - non experimental studies, such as descriptive, correlational and comparative research, with a qualitative approach and case studies; Level V - program evaluation data obtained in a systematic manner; and Level VI - expert opinions, experience reports, consensus, regulations and legislation11.
In order to facilitate the extraction and synthesis of data, a synthesis matrix described in an Excel® spreadsheet has been prepared. Data was collected such as: journal; country and year of publication; author(s); title; study design; main results, factors related to the quality of attention and level of evidence. We tried with the instrument, besides forming a database, mapping relevant points, integrating data and characterizing the revised sample. Thus, part of these data are represented in Chart 2.
Chart 2: Final sample of articles. Brasília, Distrito Federal, 2020.
![](/img/revistas/eg/v21n65//1695-6141-eg-21-65-545-gt5.png)
Elaboration: Aguiar RS, Silva HS, 2020.
The compiled data was then analyzed by means of thematic analysis27, being organized and presented in thematic categories obtained from the following stages of analysis: 1) familiarization of the data (results of the studies that composed the sample and related to the research question), 2) generation of initial codes, 3) search by themes, 4) revision of the themes, 5) definition and titling of the themes and 6) production of the report.
RESULTS
The final sample of this review consisted of fifteen articles, as described in Table 4.
A large portion of the publications refer to the year 2019 with seven articles (46.7%), followed by 2018 with three (20%), 2017 and 2015 with two each year (13.3% each year) and 2020 with one article (6.7%). Qualitative design was the most prevalent among the searches (five articles, 33.3%). As for the place of publication and development, nine studies (60%) were conducted in Brazil, three (20%) in the Netherlands, two (13.3%) in South Africa and one (6.7%) in the United States (USA). Regarding the level of evidence of the articles, there was a higher prevalence of non-experimental studies, such as descriptive, correlational and comparative research, with qualitative approach and case studies (93.3%).
The thematic analysis of the results of the articles allowed the organization in two main thematic categories: 1) potentialities associated with the quality of care for the elderly in PHC and 2) weaknesses in the quality of care for the elderly in PHC.
Potentialities associated with the quality of care for the elderly in PHC
In general, the articles brought aspects identified and/or executed by health professionals, managers and the elderly as necessary for the quality of care for the elderly in PHC. Thus, the typology of the service in the FHT model, the high coverage of PHC and the availability of the primary health care service free of charge were highlighted by articles E1, E11 and E3, respectively12)(22)(14.
The E11 study identified the Figure of the community health agent (CHA) as a strong point for the improvement of the follow-up processes of patients due to the capillarity of the FHT in the municipality, performance in family guidance, home visits to the elderly after discharge for continuity of care and investment in technical training in Nursing to professionals for a better monitoring of users in the territory22.
Among the clinical processes of monitoring the elderly in PHC, the attention to CNCD was the one that stood out the most, as found in studies E1, E3 and E1212)(23)(14.
In the perception of elderly people, it was identified that they value the discussion on the impact of diseases or treatments on their quality of life(E9)20, the service adapted to their wishes(E10)21 and the maintenance of its autonomy for decisions that impact its monitoring and health treatment (E14)25. Additionally, the continuity of care by the same health professionals was identified as a positive aspect in the E14 study25, this fact corroborates the one identified in the E13 study, which demonstrated the existence of a link due to the small turnover of health professionals. Furthermore, patient-centered communication was raised as an important marker for the quality of care 24.
Still according to the elderly, the quality of PHC was associated with the perceived productivity of their interactions with the doctor and the nurse in the E2 study13 and the construction of a relationship of trust and affection with the elderly allows for more effective actions in therapeutic practices (E11)22. The PHC physician was identified as a professional with a central role in the coordination of elderly care according to the E9 study20, but the E10 study brought that multidisciplinary collaboration in the care of the elderly allows a more satisfactory follow-up21.
Regarding the work processes of professionals, the E9 study values the provision of health education to the elderly for better decision making and accountability of their care, as well as the provision of reliable brochures or websites for research and health education20. In the E15 study, discussions on health care in elderly groups are encouraged26.
Additionally, the E11 study approached the follow-up of requests for referrals by health professionals to avoid absenteeism in care, resizing of vacancies of specialists and/or exams regulated according to the demands of the APS and the hiring of services not available in the municipality to ensure better health care, aiming at the completeness of the care22. Furthermore, the E3 study pointed out the delivery of medicines at home for fragile elderly as a factor for increasing access and accessibility14.
The E1 study demonstrated the need for constant evaluation of the care processes for monitoring and evaluating users, in addition to the need for the use of epidemiological data for a better performance in comprehensive care for the elderly12.
The relationship between professional and user was an aspect highlighted in the E9 study in which the elderly highlighted aspects necessary for the quality of care, namely: detailed explanation about the diagnoses, relevance of the evaluation, treatment and presentation of treatment options focusing on patient preference, timely communication with the doctor, listening to patients and translating their concerns as important aspects of communication, perception of comfort and confidence when the doctor is receptive to learn new information about their disease and care, in addition to listening, respect, humility and punctuality as positive characteristics in the care of the elderly20.
Weaknesses in the quality of health care for the elderly in PHC
PHC is seen as the preferential gateway for users to the UHS due to the possibility of lifelong follow-up and the completeness of care, but according to the E11 study it was possible to identify the absence of a model of care for the elderly in the services, since care is provided based on adult care, without taking into account the needs of the elderly person22. Corroborating this finding, the E10 study presents a reactive, fragmented PHC that is not able to effectively deal with the complexity of the health needs of elderly people in the community21. In addition, the elderly consider the quality of services provided in PHC to be of low quality, and their expectations regarding the service attributes are usually higher than their perceptions, according to the E7 study18.
The work and formation of an intersectoral network are fundamental in the care of the elderly, but studies E1, E11 and E12 demonstrated the absence of intersectoral and interdisciplinary support network, besides the low performance of intersectoral work, even in services with positive assessment of PHC12)(22)(3.
Although it has been identified that the attention to CNCD was the most prominent among the clinical follow-up of the elderly person, the risk stratification is still underused in the practice of care for the elderly, as demonstrated in the studies E6, E11 and E1217,22-3. In addition, there was an association between chronic health conditions and a worse perception of PHC performance in the attributes of care coordination, family counseling and community orientation in the E8 study19.
Additionally, the evaluation of the degree of fragility and the multidimensional evaluation of the elderly person was another aspect neglected by health professionals in the E5 and E8 studies16,19. In addition, the E1 study identified incipiency in the development of actions aimed at active and healthy aging12; an attention not patient-centered or inappropriate for age (E3)14; the lack of knowledge of the aging process and its implications in the health demands by the professionals, besides difficulties of performance with elderly people with functional decline or fragile elderly people (E11)22. These facts may be associated with the perceptions of the elderly identified in the E4 study in which they report that health professionals are trained to see the elderly as diseases to be treated rather than individuals with health needs15. In addition, studies E5, E11, E12 and E14 demonstrated deficiency and/or lack of permanent training/education aimed at health professionals16,22-3,25.
Regarding health promotion and prevention actions, studies E7, E11, E12 and E15 showed in their results little incorporation, inefficiency of actions contributing to the increase of emergency care, difficulty of access to information materials and non-prioritization and/or lack of health education during consultations18,22-3,26.
Table 3 shows a compilation of other weaknesses described by the studies that make up the final sample of this integrative review, as well as the possible outcomes. Intervening in the complaints system requires planning actions anchored in the adoption of evaluation protocols, follow-up and monitoring of elderly people; use of management indicators and quality of care; supply of inputs, expansion of infrastructure and better articulation of the intersectoral support network; continuing education actions for professionals who work at BHU, as well as expansion of reception actions, formation of links and health education for users.
Chart 3: Synthesis of the negative factors and possible outcomes described by the studies included in the integrative review. Brasília, Distrito Federal, 2020.
![](/img/revistas/eg/v21n65//1695-6141-eg-21-65-545-gt6.png)
Elaboration: Aguiar RS, Silva HS, 2020.
Another outstanding factor identified in studies E3, E11 and E14 was the physician's performance in which the absence of interpersonal relationship between the professional and the elderly person was verified, centralization in the medical consultation and in the model based on the production and not in the resolution of the demands of the users, besides little medical availability for the care directed to the elderly in the territory, respectively14)(22)(25.
About the performance of nurses, the E3 study showed a negative reputation of professionals by the elderly due to disinterest, judgment of value, rudeness and even aggression by nurses due to non-follow-up of treatment by the elderly14. In addition, the E6 study demonstrated that the nursing consultations were directed to complaint-conduct during the reception, with consequent referral for medical evaluation17, in addition to the existence of problems related to decision making by nurses in the E14 study25.
DISCUSSION
The health care of the elderly must be based on the provision of care practices aimed at achieving old age with independence, autonomy and productivity, as well as having a network of services articulated, integrated, referenced and with information systems constituted12,18.
In the contemporary model of care with a focus on aging and, especially, on the elderly person, it becomes necessary to gather a continuous flow of educational actions, health promotion, prevention of prevenTable diseases, postponement of aggravation and maintenance of functional capacity12)(16)(23.
Therefore, investments in human resources, permanent education, standardization and implementation of behaviors related to the health of the elderly are necessary to qualify health care so that there is an improvement in the implementation of clinical guidelines in the practice of health professionals, aiming to promote alignment of health care with the needs of the elderly person16)(7.
Furthermore, the work process of the health teams needs to be organized in order to offer an equiTable and integral care, welcoming the user and linking him/her to the services offered according to his/her real needs, because when the health demands are not identified and/or stratified, the necessary care under-supply to elderly people with higher risks and/or the over-supply of unnecessary care to those with lower needs may occur, which consequently produces ineffective and inefficient care17.
For this, risk stratification, the use of epidemiological indicators, and the evaluation of the quality of PHC services need to be institutionalized as a process of transformation of PHC practices. In addition to this need, the expectations and perceptions of the elderly are identified as a determinant for the organization of the model of care for the elderly that allows for flexibility and organization of care actions based on the needs of users in order to value and influence therapeutic adherence17)(8)(20)(22)(24.
The elderly person has biopsychosocial demands and particularities that differentiate him/her from a young and middle-aged adult user; thus, the importance of breaking with the idea of a generalized elderly care is stressed 22 to invest in a person-centered, integral, proactive and inter-rational care14)(5)(21)(26.
In view of this, the institutionalization of the process of permanent education in health tends to be an alternative for the qualification and improvement of the work processes within the scope of PHC14,25 and the creation of partnerships with educational institutions may serve as support for the realization of this measure17.
However, besides the regular institutionalization of training for professionals to expand knowledge on specific issues of aging and health of the elderly, it is necessary to reflect that for a more substantial change in the model of care may require new structures, materials and equipment, which points to the reorientation in the allocation of public funds26.
Therefore, exploring the potential of PHC services in managing care and maintaining the functional capacity of the elderly associated with networking and with the participation and co-responsibility of the elderly may overcome the fragmented system still in place in UHS14)(24)(5.
CONCLUSION
From the data obtained in the review, it is identified the existence of fragilities in the health care of the elderly in PHC that directly impact on the quality of care offered and perceived by the elderly person. Aspects that involve lack of training, protocols, inputs, human resources, infrastructure and intersectoral network were identified.
In addition, by making the association with the attributes of PHC, access and completeness are the most impacted in the provision of care for the elderly within PHC. Parallel to this, the effectiveness of the FHT model was identified as an important aspect for the health care of the elderly in the PHC, besides the active action of the CHA in the territory, as well as the need for valorization and participation of the elderly in discussions about their follow-up and treatment.
Thus, this review suggests the need for future research in order to improve the understanding of the factors associated with the quality of care for the elderly in PHC, because despite the efforts to qualify PHC through the implementation of the book of the elderly, care for CNCDs, strengthening of the FHT, provision of courses by the Open University of the UHS (UNASUS) and forums for continuing education, it has not been sufficient or is not applied comprehensively to direct care professionals. These challenges become even greater with Constitutional Amendment No. 95, which limited public spending for 20 years and with the difficulty of operating the NPHE in the last decade. There is a lack of broad and mobilizing actions to promote healthy aging, as well as the use of technical and relational devices aimed at the territory and the elderly person.
Therefore, a broader and more comprehensive view of the aging process is needed, as well as the commitment of professionals to the subject, given that aging is a growing reality in PHC and that it will be increasingly so in the coming decades.
Regarding the limitations of the study, it is believed that they are related to the use of a single international database, a fact that may have limited the expansion of the supply of scientific articles in languages other than Portuguese.
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Received: September 18, 2020; Accepted: January 13, 2021