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Peer-reviewedCC BY 4.0Lancet Regional Health - Americas

Primary care effectiveness, multimorbidity, and hospital use in public and private health-care systems in Brazil: a cross-sectional analysis of data from the 2019–2021 Brazilian longitudinal study of aging

  • Giulia Muniz de Oliveira1,2
  • Bruno Pereira Nunes3
  • Kenneth Lam4
  • Maria Fernanda Lima-Costa5
  • Juliana Lustosa Torres5,6
  • James Macinko7
  • Bruno de Souza Moreira5
  • Thiago Junqueira Avelino-Silva1,8
  • Virgílio Augusto Deodato Gonçalves1,9
  • Sileno de Queiroz Fortes-Filho10
  • Thiago Figueiredo de Castro11
  • Sandro Rogério Rodrigues Batista11,12
2 more authors
  • Eduardo Ferriolli1
  • Márlon Juliano Romero Aliberti1,8
12 affiliations
  1. 1Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
  2. 2Department of Epidemiology and Health Information, Hospital Israelita Albert Einstein, São Paulo, Brazil
  3. 3Department of Health and Kinesiology, University of Illinois Urbana-Champaign, Urbana, IL, USA
  4. 4Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
  5. 5Center for Studies in Public Health and Aging, Universidade Federal de Minas Gerais and Fundação Oswaldo Cruz, Belo Horizonte, Brazil
  6. 6Departamento de Medicina Preventiva e Social, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  7. 7Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
  8. 8Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
  9. 9Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
  10. 10School of Health Sciences, Amazonas State University (UEA), Amazonas, Brazil
  11. 11Faculty of Medicine, University of Brasilia, Brasília, DF, Brazil
  12. 12Faculty of Medicine, Federal University of Goiás, Goiânia, GO, Brazil
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Abstract

Background: Whether patient-reported experiences in primary care modify the association between multimorbidity and emergency department (ED) visits and hospitalizations remains unclear. We examined these associations across public and private health system sectors among Brazilians aged ≥50 years.

Methods: This cross-sectional study used nationally representative data from the 2019–2021 Brazilian Longitudinal Study of Aging. Multimorbidity was defined as the presence of ≥2 of 13 chronic conditions. A 12-item patient-reported primary care effectiveness index captured access, continuity, communication, and coordination with participants’ usual source of healthcare. Primary outcomes were ED visits and hospitalizations in the past 12 months. Poisson regression models estimated associations with the outcomes, and assessed interactions among multimorbidity, primary care effectiveness, and health system sectors.

Findings: Among 9058 participants (mean age = 66.3 ± 9.9 years; females = 55.3%; White race/ethnicity = 46.4%), 38.0% had multimorbidity. Overall, 12.5% reported an ED visit and 6.0% ≥ 1 hospitalization in the past 12 months. Multimorbidity was associated with approximately twice the prevalence of ED visits and three times the prevalence of hospitalizations. Primary care effectiveness modified these associations across health system sectors (three-way interaction p = 0.04 for ED visits and p < 0.001 for hospitalization). In the public system, higher primary care effectiveness attenuated the association between multimorbidity and hospitalization (interaction prevalence ratio [PR] = 0.74, 95% confidence interval [CI] = 0.63–0.87). In contrast, in the private system, higher primary care effectiveness strengthened the associations of multimorbidity with ED visits (interaction PR = 1.40, 95% CI = 1.18–1.66) and hospitalization (interaction PR = 1.75, 95% CI = 1.22–2.50).

Interpretation: Associations between multimorbidity and healthcare use varied according to patient-reported primary care experiences and health system sector.

Funding: The Brazilian National Council for Scientific and Technological Development, the Alzheimer’s Association, and the National Institute on Aging.

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Cite

BibTeXRIS
BibTeX
@article{oliveira2026primary,
  title = {{Primary care effectiveness, multimorbidity, and hospital use in public and private health-care systems in Brazil: a cross-sectional analysis of data from the 2019–2021 Brazilian longitudinal study of aging}},
  author = {Giulia Muniz de Oliveira and Bruno Pereira Nunes and Kenneth Lam and Maria Fernanda Lima-Costa and Juliana Lustosa Torres and James Macinko and Bruno de Souza Moreira and Thiago Junqueira Avelino-Silva and Virgílio Augusto Deodato Gonçalves and Sileno de Queiroz Fortes-Filho and Thiago Figueiredo de Castro and Sandro Rogério Rodrigues Batista and Eduardo Ferriolli and Márlon Juliano Romero Aliberti},
  journal = {Lancet Regional Health - Americas},
  year = {2026},
  month = oct,
  doi = {10.1016/j.lana.2026.101680},
  url = {https://doi.org/10.1016/j.lana.2026.101680},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Primary care effectiveness, multimorbidity, and hospital use in public and private health-care systems in Brazil: a cross-sectional analysis of data from the 2019–2021 Brazilian longitudinal study of aging
AU  - Giulia Muniz de Oliveira
AU  - Bruno Pereira Nunes
AU  - Kenneth Lam
AU  - Maria Fernanda Lima-Costa
AU  - Juliana Lustosa Torres
AU  - James Macinko
AU  - Bruno de Souza Moreira
AU  - Thiago Junqueira Avelino-Silva
AU  - Virgílio Augusto Deodato Gonçalves
AU  - Sileno de Queiroz Fortes-Filho
AU  - Thiago Figueiredo de Castro
AU  - Sandro Rogério Rodrigues Batista
AU  - Eduardo Ferriolli
AU  - Márlon Juliano Romero Aliberti
PY  - 2026
DA  - 2026/10/17
JO  - Lancet Regional Health - Americas
DO  - 10.1016/j.lana.2026.101680
UR  - https://doi.org/10.1016/j.lana.2026.101680
AB  - Background: Whether patient-reported experiences in primary care modify the association between multimorbidity and emergency department (ED) visits and hospitalizations remains unclear. We examined these associations across public and private health system sectors among Brazilians aged ≥50 years.  Methods: This cross-sectional study used nationally representative data from the 2019–2021 Brazilian Longitudinal Study of Aging. Multimorbidity was defined as the presence of ≥2 of 13 chronic conditions. A 12-item patient-reported primary care effectiveness index captured access, continuity, communication, and coordination with participants’ usual source of healthcare. Primary outcomes were ED visits and hospitalizations in the past 12 months. Poisson regression models estimated associations with the outcomes, and assessed interactions among multimorbidity, primary care effectiveness, and health system sectors.  Findings: Among 9058 participants (mean age = 66.3 ± 9.9 years; females = 55.3%; White race/ethnicity = 46.4%), 38.0% had multimorbidity. Overall, 12.5% reported an ED visit and 6.0% ≥ 1 hospitalization in the past 12 months. Multimorbidity was associated with approximately twice the prevalence of ED visits and three times the prevalence of hospitalizations. Primary care effectiveness modified these associations across health system sectors (three-way interaction p = 0.04 for ED visits and p < 0.001 for hospitalization). In the public system, higher primary care effectiveness attenuated the association between multimorbidity and hospitalization (interaction prevalence ratio [PR] = 0.74, 95% confidence interval [CI] = 0.63–0.87). In contrast, in the private system, higher primary care effectiveness strengthened the associations of multimorbidity with ED visits (interaction PR = 1.40, 95% CI = 1.18–1.66) and hospitalization (interaction PR = 1.75, 95% CI = 1.22–2.50).  Interpretation: Associations between multimorbidity and healthcare use varied according to patient-reported primary care experiences and health system sector.  Funding: The Brazilian National Council for Scientific and Technological Development, the Alzheimer’s Association, and the National Institute on Aging.
SN  - 2667-193X
ER  -