Development of an Index to Assess COVID-19 Hospital Care Installed Capacity in the 450 Brazilian Health Regions.

OBJECTIVE: The article seeks to assess the Brazilian health system ability to respond to the challenges imposed by the coronavirus disease 2019 (COVID-19) pandemic by measuring the capacity of Brazilian hospitals to care for COVID-19 cases in the 450 Health Regions of the country during the year 2020. Hospital capacity refers to the availability of hospital beds, equipment, and human resources. METHODS: We used longitudinal data from the National Register of Health Facilities (CNES) regarding the availability of resources necessary to care for patients with COVID-19 in inpatient facilities (public or private) from January to December 2020. Among the assessed resources are health professionals (certified nursing assistants, nurses, physical therapists, and doctors), hospital beds (clinical, intermediate care, and intensive care units), and medical equipment (computed tomography scanners, defibrillators, electrocardiograph monitors, ventilators, and resuscitators). In addition to conducting a descriptive analysis of absolute and relative data (per 10,000 users), a synthetic indicator named Installed Capacity Index (ICI) was calculated using the multivariate principal component analysis technique to assess hospital capacity. The indicator was further stratified into value ranges to understand its evolution. RESULTS: There was an increase in all selected indicators between January and December 2020. It was possible to observe differences between the Northeast and North regions and the other regions of the country; most Health Regions presented low ICI. The ICI increased between the beginning and the end of 2020, but this evolution differed among Health Regions. The average increase in the ICI was more evident in the groups that already had considerably high baseline capacity in January 2020. CONCLUSIONS: It was possible to identify inequalities in the hospital capacity to care for patients affected by COVID -19 in the Health Regions of Brazil, with a concentration of low index values in the Northeast and North of the country. As the indicator increased throughout the year 2020, inequalities were also observed. The information here provided may be used by health authorities, providers, and managers in planning and adjusting for future COVID-19 care and in dimensioning the adequate supply of hospital beds, health-care professionals, and devices in Health Regions to reduce associated morbidity and mortality. We recommend that the ICI continue to be calculated in the coming months of the pandemic to monitor the capacity in the country's Health Regions.

Geographical variation in demand, utilization, and outcomes of hospital services for COVID-19 in Brazil: A descriptive serial cross-sectional study.

OBJECTIVE: To analyze the geographical variation in the provision of health services, namely in demand, patterns of utilization, and effectiveness in the Brazilian Health Regions in four different periods of the COVID-19 pandemic, from February 2020 to March 2021. METHODS: Descriptive serial cross-sectional study based on secondary data on COVID-19 hospitalizations from SIVEP-Gripe, a public and open-access database of Severe Acute Respiratory Illness records collected by the Brazilian Ministry of Health, and COVID-19 case notification data from Brasil.io, a repository of public data. Fifty-six epidemiological weeks were split into four periods. The following variables were considered for each Brazilian Health Region, per period: number of hospitalizations, hospitalizations per 100,000 inhabitants, hospitalizations per 100 new cases notified in the Health Region, percentage of hospitalizations with ICU use, percentages of hospitalizations with invasive and non-invasive ventilatory support, percentage of hospitalizations resulting in death and percentage of hospitalizations with ICU use resulting in death. Descriptive statistics of the variables were obtained across all 450 Health Regions in Brazil over the four defined pandemic periods. Maps were generated to capture the spatiotemporal variation and trends during the first year of the COVID-19 pandemic in Brazil. RESULTS: There was great variation in how COVID-19 hospitalizations grew and spread among Health Regions, with higher numbers between June and August 2020, and, especially, from mid-December 2020 to March 2021. The variation pattern in the proportion of ICU use in the hospitalizations across the Health Regions was broad, with no intensive care provision in large areas in the North, Northeast, and Midwest. The proportions of hospitalizations and hospitalizations with ICU use resulting in deaths were remarkably high, reaching medians of 34.0% and 62.0% across Health Regions, respectively. CONCLUSION: The Heath Regions in Brazil are highly diverse, showing broad disparities in the capacity to respond to the demands imposed by COVID-19, services provided, use and outcomes.

Trends in COVID-19 case-fatality rates in Brazilian public hospitals: A longitudinal cohort of 398,063 hospital admissions from 1st March to 3rd October 2020.

BACKGROUND: Almost 200,000 deaths from COVID-19 were reported in Brazil in 2020. The case fatality rate of a new infectious disease can vary by different risk factors and over time. We analysed the trends and associated factors of COVID-19 case fatality rates in Brazilian public hospital admissions during the first wave of the pandemic. METHODS: A retrospective cohort of all COVID-19-related admissions between epidemiological weeks 10-40 in the Brazilian Public Health System (SUS) was delimited from available reimbursement records. Smoothing time series and survival analyses were conducted to evaluate the trends of hospital case fatality rates (CFR) and the probability of death according to factors such as sex, age, ethnicity, comorbidities, length of stay and ICU use. RESULTS: With 398,063 admissions and 86,452 (21.7%) deaths, the overall age-standardized hospital CFR trend decreased throughout the period, varying from 31.8% (95%CI: 31.2 to 32.5%) in week 10 to 18.2% (95%CI: 17.6 to 18.8%) in week 40. This decreasing trend was observed in all sex, age, ethnic groups, length of stay and ICU admissions. Consistently, later admission (from July to September) was an independent protective factor. Patients 80+ year old had a hazard ratio of 8.18 (95% CI: 7.51 to 8.91). Ethnicity, comorbidities, and ICU need were also associated with the death risk. Although also decreasing, the CFR was always around 40-50% in people who needed an ICU admission. CONCLUSIONS: The overall hospital CFR of COVID-19 has decreased in Brazilian public hospitals during the first wave of the pandemic in 2020. Nevertheless, during the entire period, the CFR was still very high, suggesting the need for improving COVID-19 hospital care in Brazil.

COVID-19 hospitalizations in Brazil's Unified Health System (SUS).

OBJECTIVE: To study the profile of hospitalizations due to COVID-19 in the Unified Health System (SUS) in Brazil and to identify factors associated with in-hospital mortality related to the disease. METHODS: Cross-sectional study, based on secondary data on COVID-19 hospitalizations that occurred in the SUS between late February through June. Patients aged 18 years or older with primary or secondary diagnoses indicative of COVID-19 were included. Bivariate analyses were performed and generalized linear mixed models (GLMM) were estimated with random effects intercept. The modeling followed three steps, including: attributes of the patients; elements of the care process; and characteristics of the hospital and place of hospitalization. RESULTS: 89,405 hospitalizations were observed, of which 24.4% resulted in death. COVID-19 patients hospitalized in the SUS were predominantly male (56.5%) with a mean age of 58.9 years. The length of stay ranged from less than 24 hours to 114 days, with a mean of 6.9 (±6.5) days. Of the total number of hospitalizations, 22.6% reported ICU use. The odds on in-hospital death were 16.8% higher among men than among women and increased with age. Black individuals had a higher likelihood of death. The behavior of the Charlson and Elixhauser indices was consistent with the hypothesis of a higher risk of death among patients with comorbidities, and obesity had an independent effect on increasing this risk. Some states, such as Amazonas and Rio de Janeiro, had a higher risk of in-hospital death from COVID-19. The odds on in-hospital death were 72.1% higher in municipalities with at least 100,000 inhabitants, though being hospitalized in the municipality of residence was a protective factor. CONCLUSION: There was broad variation in COVID-19 in-hospital mortality in the SUS, associated with demographic and clinical factors, social inequality, and differences in the structure of services and quality of health care.

Estimates of the impact of COVID-19 on mortality of institutionalized elderly in Brazil

Resumo O presente estudo tem como objetivo estimar o impacto da COVID-19 na mortalidade de idosos institucionalizados no Brasil. Foram estimados números de óbitos pela doença para o País, Unidades da Federação e Regiões, com base nas estimativas calculadas e efetuadas neste trabalho do percentual de óbitos de idosos que ocorreriam em instituições de longa permanência de acordo com os totais. Essa estimativa foi baseada em informações disponíveis para uma série de países. O percentual ponderado foi de 44,7%. Estimaram-se 107.538 óbitos de idosos nestas instituições no Brasil em 2020, por COVID-19. São previstos maiores números de óbitos na Região Sudeste (48.779 óbitos), seguida da Região Nordeste (28.451 óbitos);São Paulo é a Unidade da Federação que na estimativa será mais afetada (24.500 óbitos). Fica claro o forte impacto da COVID-19 na população idosa residente em instituições de longa permanência para idosos. As estimativas ultrapassam para o país 100 mil idosos, potencialmente os mais frágeis e vulneráveis, e são baseadas em número de óbitos totais conservador, tendo em vista outras estimativas e a situação alarmante de crescimento dos números de óbitos no Brasil. The COVID-19 pandemic poses difficulties for long-term care institutions for the elderly, with increased mortality rates for the residents. This study aims to estimate the impact of COVID-19 on mortality of institutionalized elderly in Brazil. Estimates of the percentage of elderly deaths occurring in care homes were calculated for Brazil, States and Regions using estimates for the total number of deaths. The estimation was based upon information available for other countries. The weighted percentage was 44.7% and 107,538 COVID-19 deaths were estimated for the elderly in these institutions in Brazil in 2020. Higher numbers of deaths were expected in the Southeast Region (48,779 deaths), followed by the Northeast Region (28,451 deaths);São Paulo was the most affected State (24,500 deaths). The strong impact of COVID-19 on the elderly population living in long-term care facilities is clear. Estimates for the country exceeded 100,000 elderly people, potentially the most fragile and vulnerable, and are based upon a conservative number of total deaths, in view of other estimates and the alarming situation of death growth in Brazil from COVID-19.

The Civil Registry in the first four months of the Covid-19 pandemic in Brazil: a comparative study between deaths by month of occurrence and by month of registration / O Registro Civil nos quatro primeiros meses da pandemia de Covid-19 no Brasil: estudo comparativo entre óbitos por mês de ocorrência e de registro / El Registro Civil en los primeros cuatro meses de la pandemia de covid-19 en Brasil: un estudio comparativo entre muertes por mes de ocurrencia y por mes de registro

O Registro Civil fornece informações aos estudos demográficos sobre mortalidade, fecundidade e nupcialidade. Questões têm surgido sobre o registro dos óbitos quando as causas de morte decorrem da Covid-19. A notificação pode acontecer com atraso. Com base nas informações disponibilizadas pelo Registro Civil de óbitos pela Covid-19, discriminados por dois grupos - data de registro e data de ocorrência -, o presente estudo compara estes grupos por categoria de município (capital, região metropolitana e interior), no período de março a junho de 2020, que corresponde aos quatro primeiros meses da pandemia no Brasil. Avaliam-se a magnitude e o sentido das diferenças de registros de óbitos entre os dois grupos. Foram utilizados gráficos e análise de regressão linear para comparações. Os achados indicam comportamento diferente de óbitos por mês de registro em comparação àqueles por mês de ocorrência entre março e junho. É importante identificar tal diferença de comportamentos dado que, para o monitoramento em curtíssimo prazo da pandemia, óbitos por data de registro antecipam óbitos cujo registro ainda será corretamente disponibilizado por data de ocorrência. Conclui-se que essa variação deve-

The Civil Registry provides information on demographic studies on mortality, fertility and nuptiality. Questions have been raised about death registration when the causes of death are related to Covid-19. Notification may be delayed. Based on information provided by the Civil Registry of deaths, stratified by two groups - date of registration and date of occurrence - by Covid-19, this study compares these groups by city categories (capital, metropolitan region, interior), over March, April, May and June 2020, occurring in the first four months of the pandemic in Brazil. The magnitude and meaning of the differences in death records between the two groups were assessed. Graphs and linear regression analyses were used for comparisons. The findings indicate a different behavior of deaths per month of registration compared to deaths per month of occurrence between March and June. It is important to identify such a difference in behavior since, for the very short-term monitoring of the pandemic, deaths from registry data anticipate deaths whose records will still be adequately available by occurrence data. Such variation occurs mainly due to the systematic correction and updating of the information. As for the city categories, the biggest difference between deaths by month of occurrence and registration was observed for the municipalities in the interior, in line with the spread of the epidemic towards the interior in the month of May.

El Registro Civil proporciona información sobre estudios demográficos en mortalidad, fecundidad y nupcialidad. Se han planteado preguntas sobre el registro de muertes cuando las causas de muerte son por covid-19, ya que la notificación puede producirse tarde. Con base en la información proporcionada por el Registro Civil de Defunciones, desglosada en dos grupos -fecha de inscripción y fecha de ocurrencia- por covid-19, este estudio los compara por tipo de municipio (capital, región metropolitana, interior), sobre los meses de marzo, abril, mayo y junio de 2020, corresponden a primeros cuatro meses de la pandemia en Brasil. Se evalúa la magnitud y el significado de las diferencias en los registros de defunción entre los dos grupos. Para las comparaciones se utilizaron gráficos y análisis de regresión lineal. Los hallazgos indican un comportamiento diferente de las muertes por mes de registro en comparación con las muertes por mes de ocurrencia entre marzo y junio. Es importante identificar tal diferencia en el comportamiento ya que, para el monitoreo a muy corto plazo de la pandemia, las muertes a partir de los datos del registro anticipan muertes cuyos registros aún estarán disponibles correctamente mediante los datos de ocurrencia. Se concluye que esta variación se produce principalmente por la corrección y actualización sistemática de la información. En cuanto al tipo de municipio, la mayor diferencia entre defunciones por mes de ocurrencia y de registro se registró para los municipios del interior, en línea con la propagación de la epidemia hacia el interior, en mayo.

Estimates of the impact of COVID-19 on mortality of institutionalized elderly in Brazil. / Estimativas de impacto da COVID-19 na mortalidade de idosos institucionalizados no Brasil.

The COVID-19 pandemic poses difficulties for long-term care institutions for the elderly, with increased mortality rates for the residents. This study aims to estimate the impact of COVID-19 on mortality of institutionalized elderly in Brazil. Estimates of the percentage of elderly deaths occurring in care homes were calculated for Brazil, States and Regions using estimates for the total number of deaths. The estimation was based upon information available for other countries. The weighted percentage was 44.7% and 107,538 COVID-19 deaths were estimated for the elderly in these institutions in Brazil in 2020. Higher numbers of deaths were expected in the Southeast Region (48,779 deaths), followed by the Northeast Region (28,451 deaths); São Paulo was the most affected State (24,500 deaths). The strong impact of COVID-19 on the elderly population living in long-term care facilities is clear. Estimates for the country exceeded 100,000 elderly people, potentially the most fragile and vulnerable, and are based upon a conservative number of total deaths, in view of other estimates and the alarming situation of death growth in Brazil from COVID-19.