Use of health services by Brazilian older adults with and without functional limitation

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1 Rev Sude Pulic. 2017;51 Suppl 1:5s Supplement NCD nd Surveys Originl Article Use of helth services y Brzilin older dults with nd without functionl limittion Alexndre Moreir de Melo Silv I, Julin Vz de Melo Mmrini II, Sérgio Vin Peixoto II,III, Deorh Crvlho Mlt IV, Mri Fernnd Lim-Cost II I Progrm de Pós-Grdução em Súde Coletiv. Centro de Pesquiss René Rchou. Fundção Oswldo Cruz. Belo Horizonte, MG, Brsil II Núcleo de Estudos em Súde Púlic e Envelhecimento. Centro de Pesquiss René Rchou. Fundção Oswldo Cruz. Belo Horizonte, MG, Brsil III Deprtmento de Enfermgem Aplicd. Escol de Enfermgem. Universidde Federl de Mins Geris. Belo Horizonte, MG, Brsil IV Deprtmento de Enfermgem Mterno Infntil e Súde Púlic. Escol de Enfermgem. Universidde Federl de Mins Geris. Belo Horizonte, MG, Brsil ABSTRACT Correspondence: Mri Fernnd Lim-Cost Centro de Pesquiss René Rchou d Fundção Oswldo Cruz Av. Augusto de Lim, Belo Horizonte, MG, Brsil E-mil: lim-cost@cpqrr.fiocruz.r Received: 1 Sep 2016 Approved: 16 Oct 2016 How to cite: Silv AMM, Mmrini JVM, Peixoto SV, Mlt DC, Lim-Cost MF. Use of helth services y Brzilin older dults with nd without functionl limittion. Rev Sude Pulic. 2017;51 Suppl 1:5s. Copyright: This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution License, which permits unrestricted use, distriution, nd reproduction in ny medium, provided tht the originl uthor nd source re credited. OBJECTIVE: To nlyze the use of helth services nd the qulity of medicl cre received y Brzilin older dults with nd without functionl limittion. METHODS: The min nlyses were sed on ntionl smple representing 23,815 prticipnts of the Ntionl Survey on Helth (PNS) ged 60 yers or older. Functionl limittion ws defined y the difficulty to perform t lest one out of ten sic or instrumentl ctivities of dily living. Potentil confounding vriles included predisposing nd enling fctors of the use of helth services. RESULTS: The prevlence of functionl limittion ws 30.1% (95%CI ). The numer of doctor visits nd hospitliztions in the pst 12 months showed sttisticlly significnt ssocitions with functionl limittion, oth for users of the pulic system (OR = 2.48 [95%CI ] for three or more doctor visits nd OR = 2.58 [95%CI ] for one or more hospitliztions) nd of the privte system (OR = 2.56 [95%CI ] nd OR = 2.22 [95%CI ], respectively). The propensity to use sic helth units ws higher mong users of the privte system with functionl limittions (OR = 2.01 [95%CI ]). Only two out of seven indictors of the qulity of medicl cre received were ssocited with functionl limittion, in the perception of users of pulic nd privte systems. The pulic system users with functionl limittions did worse evlution of the freedom for choosing the doctor nd witing time for n ppointment, when compred with users of the sme system without these limittions (OR = 0.81 [95%CI ] nd OR = 0.76 [95%CI ], respectively). CONCLUSIONS: Older dults with functionl limittions use more helth services in comprison with those without such limittions. The mgnitude of the ssocition etween functionl limittion nd numer of doctor visits nd hospitliztions ws similr in the pulic nd privte helth systems. DESCRIPTORS: Aged. Fril Elderly. Disled Persons. Activities of Dily Living. Helth Services for the Aged. Qulity of Helth Cre. 1s

2 INTRODUCTION The ging of the popultion occurs worldwide, nd Brzil the fifth lrgest popultion in the world is one of the countries where this demogrphic trnsition hs een occurring more rpidly. Aged popultions hve higher urden of chronic diseses nd disilities, leding to incresed demnd for helth cre. There is, therefore, growing interest in nlyzing the profile nd inequlities ssocited with the use of helth services y older dults with functionl limittions, oth in countries with ged popultions nd in those with rpid ging process 1-3. The determinnts of use of helth-cre services re relted to contextul fctors (types of helth systems nd their orgniztion, for exmple) 4 nd individul fctors. According to the clssicl model of Andersen nd Newmn 5, individul fctors comprehend predisposing chrcteristics (such s ge nd sex), enling chrcteristics (such s eduction level nd income), nd helth needs. In Brzil, the orgniztion of helth cre is sed on the Brzilin Unified Helth System (SUS), which is responsile for the universl nd free provision of helth services nd progrms 6. The pulic system coexists with the privte one, which requires pyment to ccess it 6. Adults covered y privte helth insurnces perform more medicl nd dentl ppointments in comprison to the rest of the popultion 7. In the perception of the dult popultion, the min differences etween the cre received in the pulic helth system nd tht received in the privte one re: how to schedule doctor visit (with predominnce of prescheduling in the ltter); the witing time to get the doctor visit (longest in the former); the type of doctor (predominnce of generl prctitioner in the former); nd the reson for the doctor visit (predominnce of periodic helth exmintion in the ltter) 8. The prevlence of functionl limittion vries etween countries nd on the sis of the criterion dopted for its definition 9,. A widely used definition is the report of difficulties to perform sic or instrumentl ctivities of dily living. Bsed on this definition, the prevlence of functionl limittions in the popultion ged 50 yers or older rnges etween 25% in Spin nd Englnd nd 40% in the United Sttes 10. United Ntions, Deprtment of Economic nd Socil Affirs, Popultion Division. World popultion prospects: the 2015 revision. New York; 2015 [cited 2015 Dec 3]. Aville from: Orgnizção Mundil d Súde. Rumo um lingugem comum pr funcionlidde, incpcidde e súde: CIF Clssificção Interncionl de Funcionlidde, Incpcidde e Súde. Gener; 2002 [cited 2016 Jn 20]. Aville from: c Instituto Brsileiro de Geogrfi e Esttístic, Coordenção de Trlho e Rendimento. Pesquis Ncionl de Súde 2013: cesso e utilizção dos serviços de súde, cidentes e violêncis: Brsil, grndes regiões e uniddes d federção. Rio de Jneiro: IBGE; 2015 [cited 2016 Jn 20]. Aville from: visulizco/livros/liv94074.pdf In Brzil, popultion-sed studies exmining the ssocition etween functionl limittion nd use of helth services re scrce. A study conducted in cities of South nd Northest regions showed tht, mong older dults with chronic diseses, the prevlence of doctor visits ws 30% higher mong those with some level of functionl limittion, when compred with those without such limittions 11. Another study, conducted in the metropolitn region of Belo Horizonte, showed tht functionl limittions were ssocited with incresed hospitliztions nd doctor visits t the household 12. In this study, we used dt from the Ntionl Survey on Helth (PNS) to nlyze the use of helth services nd the qulity of medicl cre received in the perception of Brzilin older dults with nd without functionl limittion. METHODS The PNS ws held in 2013 y the Brzilin Institute of Geogrphy nd Sttistics (IBGE) in prtnership with the Brzilin Ministry of Helth c. The survey ws designed to represent the dult popultion, sed on complex smpling 13,c. PNS consists of three questionnires: household; individul to e responded for ll residents; individul to e responded y selected dult resident. All residents in the smpled households ged 60 yers or older were eligile to respond to the module on functionl cpcity. The selected dult resident ws eligile to respond to the module on medicl cre. For this study, ll prticipnts from the survey ged 60 yers or older were selected for the nlysis of the fctors ssocited with the use of helth services (n = 23,815), nd the selected residents in the sme ge group were selected for the nlysis of the indictors of qulity of medicl cre received (n = 9,290). 2s

3 The structure of the PNS questionnire consists of seprte questions on the degree of difficulty to perform different ctivities of dily life, with response options rnging etween no difficulty, little difficulty, gret difficulty, nd cnnot perform it t ll. This nlysis considered six sic ctivities (feeding; thing; using the toilet; dressing; wlking t home from one room to nother on the sme floor; nd lie down or get up from ed) nd four instrumentl ctivities of dily living (shopping; mnging own finnces; tking medictions; nd leving home using trnsporttion). Functionl limittion ws ssigned to those who reported some degree of difficulty to perform t lest one of the ove mentioned ctivities. The source of cre ws ctegorized into pulic system users nd privte system users. The ltter were defined y the report of hving privte helth pln, from compny or pulic gency, except for exclusively dentl pln. The use of the pulic system ws ssigned to those who did not hve privte helth pln, even if, possily, it hs pid ll or prt of the received cre. Five indictors of use of helth services were considered: numer of doctor visits performed in the pst 12 months; occurrence of one or more hospitliztions in the pst 12 months; specilty of the doctor in the lst ppointment (generlist versus specilist); existence of service or doctor of reference; nd loction usully sought for helth cre, mong those who reported hving service or doctor of reference. The numer of doctor visits ws ctegorized s ove (three or more doctor visits) nd elow the medin. The condition of hving reference doctor or service ws ssigned to those who reported hving service or doctor tht they usully seek when needing helth cre. The loction of the serch ws ctegorized s sic helth unit (UBS); doctor s office or privte clinic; emergency room services (emergency cre or first id units of pulic or privte hospitl); nd elsewhere. The qulity of the medicl cre received ws defined y the user rting regrding the lst doctor visit. Seven indictors were considered: physicin s ility to tret the study prticipnts; physicin s respect in the wy of serving them; clrity in the physicin s explntions; vilility of time for sking questions out the prolem or tretment; possiility to tlk in privcy with the doctor; freedom to choose the doctor; nd witing time for the ppointment. In the PNS questionnire, the questions out the perception of medicl cre hd five response options, rnging from very good to very d. In this nlysis, responses were ctegorized into very good or good versus regulr, d, or very d. The selection of potentil confounding vriles for this nlysis ws sed on the theoreticl model of Andersen nd Newmn 5, considering predisposing nd enling fctors for the use of helth services. Among the predisposing fctors, sex nd ge (continuous vrile) were considered. Among the enling fctors, living with spouse/prtner (yes or no) nd eduction level (ctegorized into five groups, rnging from no eduction to high school or more) were considered. The response vriles were the indictors of use of helth services nd of the qulity of medicl cre received, s descried ove. The exposure of interest ws the functionl limittion, s previously defined. Bivrite nlysis ws sed on prevlence estimtes nd 95% confidence intervls. Liner regression nd Person s Chi-squre test were used to exmine the sttisticl significnce of the differences etween mens nd proportions, respectively. The multivrite nlysis of the ssocition etween functionl limittion nd indictors of use of helth services nd qulity of medicl cre ws sed on odds rtio (OR) estimtes y inry or multinomil logistic regression 14,15. The ltter ws used when the response vrile hd more thn two ctegories, s ws the cse of the loction sought for helth cre (four ctegories) nd numer of doctor visit (three ctegories). Binry logistic regression ws used in the other situtions. The multivrite models were djusted for ge, sex, living with spouse/prtner, nd eduction level. The nlyses were strtified y the source of helth cre (pulic nd privte). 3s

4 Multinomil logistic regression nd inry logistic regression were used to estimte, respectively, the predicted proility of occurrence of three or more doctor visits nd one or more hospitliztions in the pst 12 months, ccording to functionl limittion nd source of helth cre. All nlyses were performed using the procedures for complex smples of the sttisticl pckge Stt (version 13.0), considering the individul weights nd smpling prmeters. PNS ws conducted in conformity with the prmeters set out in the Declrtion of Helsinki. The survey ws pproved y the Ntionl Humn Suject Reserch Ethics Committee (CONEP Process: 328,159, June 26, 2013) 13. RESULTS Among the 23,815 older dults who took prt in the smple, 29.2% (95%CI ) hd privte helth insurnce nd 30.1% presented functionl limittion. The prevlence of functionl limittion ws significntly higher mong users of the pulic system (32.2%) when compred with those of the privte system (25.1%). More detils on the sociodemogrphic chrcteristics of the survey prticipnts nd their distriutions ccording to source of helth cre cn e seen in Tle 1. Tle 2 presents the results of the ivrite nlysis of the ssocition etween functionl limittion, indictors of use of helth services, nd indictors of qulity of medicl cre received, ccording to source of helth cre. The numer of doctor visits nd the occurrence of one or more hospitliztions in the pst 12 months showed sttisticlly significnt ssocitions (p < 0.05) with functionl limittions, mong users of oth pulic nd privte helth systems. Users of the pulic system reported higher proportion of cre y generl prctitioner, regrdless of the functionl limittion, in comprison to users of the privte system. In the ltter, the percentge of cre y this professionl ws significntly higher mong older dults with functionl limittions when compred with those without such limittions. The UBS ws the min plce sought for helth cre mong pulic system users with nd without functionl limittion, while, in oth groups, the doctor s office or privte clinic ws the predominnt loction of serch y older dults covered y privte helth insurnce. When compring those with nd without functionl limittions, the incresed demnd for UBS ws significntly higher mong privte system users with limittions (18.2%) when compred with users of the sme system without limittions (9.8%). In ivrite nlysis, other indictors of use of Tle 1. Sociodemogrphic chrcteristics of smple prticipnts ged 60 yers or older, ccording to source of helth cre. Ntionl Survey on Helth, (n = 23,815). Chrcteristic Men or percentge Totl Source of helth cre Privte Pulic (95%CI) Men or Men or (95%CI) (95%CI) percentge percentge Age, men < Femle sex, % < Living with spouse/prtner, % < Eduction level, % Hs never studied < Some elementry or middle school Elementry or middle school/some high school High school or more < Functionl limittion c, % < Mens nd percentges estimted considering the individul weights nd smpling prmeters. Person s Chi-squre test for differences etween frequency nd liner regression for difference etween the mens. c Difficulty to perform one or more sic or instrumentl ctivities of dily living. p 4s

5 Tle 2. Bivrite nlysis of the ssocition etween functionl limittion, indictors of use of helth services, nd indictors of medicl cre qulity in the lst doctor visit crried out mong smple prticipnts ged 60 yers or older, ccording to source of helth cre. Ntionl Survey on Helth, Pulic Privte Indictor With limittion Without limittion With limittion Without limittion % 95%CI % 95%CI % 95%CI % 95%CI Use of helth services (n = 23,815) Numer of doctor visits in the pst 12 months None c c One or more hospitliztions in the pst 12 months c c Medicl cre y generl prctitioner in the lst doctor visit d c Hs helth service or doctor of reference Loction usully sought (mong those who hve helth service or doctor of reference) Bsic helth unit c c Doctor s office or privte clinic Emergency room service Other Qulity of medicl cre on the lst doctor visit (very good/good versus regulr/d/very d) (n = 9,290) Physicin s ility to tret them Physicin s respect in the wy of serving them Clrity in the physicin s explntions Avilility of time for sking questions out the prolem Possiility to tlk in privcy with the doctor Freedom to choose the doctor Witing time for the ppointment Difficulty to perform one or more sic or instrumentl ctivities of dily living. Percentges nd 95% confidence intervls estimted considering the individul weights nd smpling prmeters. c p < 0.05 for differences etween the groups with nd without functionl limittion (Person s Chi-squre test). d Generl prctitioner, fmily nd community doctor, or internist. services nd qulity of cre received did not show sttisticlly significnt ssocitions with functionl limittion. However, we highlight tht, in most indictors of stisfction with the qulity of medicl cre received, the prevlence of those who ssessed these criteri s good or very good ws ove 75% for most indictors nlyzed in oth pulic nd privte systems. The lowest prevlence ws for freedom for choosing the doctor nd witing time, which were lower mong users of the pulic system. Tle 3 presents the results of multivrite nlysis of the ssocition etween functionl limittion nd the ove-mentioned indictors. After djustments for predisposing nd enling fctors, the numer of doctor visits in the pst 12 months showed strong ssocition with functionl limittion oth mong users of the pulic system (OR = 1.39; 95%CI for one or two doctor visits nd OR = 2.48; 95%CI for three or more doctor visits) nd of the privte system (OR = 1.20; 95%CI nd OR = 2.56; 95%CI , respectively). Functionl limittion lso showed strong ssocition with the occurrence of one or more hospitliztions in oth groups (OR = 2.58; 95%CI nd OR = 2.22; 95%CI , respectively). The previously mentioned ssocition etween functionl limittion nd cre y generl prctitioner in the privte system hs lost sttisticl significnce in multivrite nlysis. The greter use of UBS mong privte system users with limittions remined fter djustment for these covrites (OR = 2.01; 95%CI ). Between users of the pulic system (ut not of the privte one), the freedom for choosing the doctor nd the witing time presented independent nd negtive ssocitions with functionl limittion (OR = 0.81; 95%CI nd OR = 0.76; 95%CI , respectively). The Figure shows the predicted proility of occurrence of three or more doctor visits nd one or more hospitliztions in the different ges, ccording to functionl limittion nd source of helth cre. The proility of occurrence of three or more doctor visits showed 5s

6 cler strtifiction in ll ges, with greter proility mong older dults with functionl limittions using the privte system, followed y those with functionl limittions using the pulic system nd y those without functionl limittions using privte nd pulic systems, respectively. The sme strtifiction ws oserved for the proility of occurrence of one or more hospitliztions. Tle 3. Assocition etween functionl limittion, indictors of use of helth services, nd indictors of medicl cre qulity in the lst doctor visit crried out mong smple prticipnts ged 60 yers or older, ccording to source of helth cre (Ntionl Survey on Helth, 2013). Indictors Use of helth services (n = 23,815) Numer of doctor visits in the pst 12 months (versus none) Pulic Privte OR 95%CI OR 95%CI c c c One or more hospitliztions in the pst 12 months c c Medicl cre y generl prctitioner in the lst doctor visit d Hs helth service or doctor of reference Loction usully sought (mong those with helth service or doctor of reference) (versus others) Bsic helth unit c Doctor s office or privte clinic Emergency room service Qulity of medicl cre in the lst doctor visit (very good/good versus regulr/d/very d) (n = 9,290) Physicin s ility to tret them Physicin s respect in the wy of serving them Clrity in the physicin s explntions Avilility of time for sking questions out the prolem Possiility to tlk in privcy with the doctor Freedom to choose the doctor c Witing time for the ppointment c Difficulty to perform one or more sic or instrumentl ctivities of dily living. Odds rtio nd 95% confidence intervl djusted for ge, sex, living with spouse or prtner, nd eduction level nd estimted y multinomil logistic regression (numer of doctor visits nd loction usully sought) nd inry logistic regression (other events); the exposure ctegory ws the functionl limittion nd the response vriles were the indictors of use of helth services nd the qulity of medicl cre received. c p < 0.05 (Wld test). d Generl prctitioner, fmily nd community doctor, or internist. Doctor visits Hospitliztions.8.25 Predicted proility Predicted proility Age (yers) Age (yers) Privte nd with limittion Pulic nd with limittion Privte nd without limittion Pulic nd without limittion Models djusted for ge, sex, living with spouse or prtner, nd eduction level nd estimted y multinomil logistic regression (numer of doctor visits) nd inry logistic regression (hospitliztions). Difficulty to perform one or more sic or instrumentl ctivities of dily living. Figure. Predicted proility for three or more doctor visits nd one or more hospitliztions in the pst 12 months long ge continuum, ccording to functionl limittion nd source of helth cre. Ntionl Survey on Helth, s

7 DISCUSSION The results of this study showed tht older dults with functionl limittions perform more doctor visits nd re more prone to occurrence of hospitliztions, regrdless of predisposing fctors, such s ge nd sex, nd enling fctors, such s living with spouse/prtner nd eduction level. We oserved strong ssocitions etween functionl limittion nd incresed numer of doctor visits, s well s etween functionl limittion nd occurrence of one or more hospitliztions, oth in the pulic nd privte systems. These results re similr to those from ntionl helth surveys tht oserved ssocition etween functionl limittion nd incresed numer of doctor visits or hospitliztions in different countries such s United Sttes 1, Chin 2, South Kore 16, nd Tiwn 3. The min explntion for the incresed use of helth services y older dults with functionl limittions lies in the higher prevlence of chronic diseses nd comoridities (nd the risk of complictions relted to them), which, in turn, led to the incresed use of medictions 1,2,17. The doctor visit is positive spect of helth cre, for eing n opportunity for erly dignosis, prevention, tretment 18, nd referrls to rehilittion, when pproprite. However, the excessive use of helth services is n indictor of cre with low solution. Hospitliztions, prticulrly, cn e prevented, if unnecessry. In fct, complictions of severl diseses cn e prevented with effective ctions from the primry helth cre 19. A Brzilin study, sed on out 60 million hospitliztions tht took plce etween 1999 nd 2007 within SUS, showed tht geogrphic res with more hospitliztions y conditions relted to primry helth cre were those with more privte or chritle hospitls nd with low coverge of the Fmily Helth Strtegy. In contrst, hospitliztions y these conditions were less frequent in res with greter coverge of the Fmily Helth Strtegy nd less privte or chritle eds 20. A qulity primry helth cre is n importnt strtegy to void unnecessry hospitliztions of older dults with functionl limittions. Few studies, sed on ntionl representtive smples, exmined the socil inequlities ssocited with the use of helth services y older dults with functionl limittions. In the United Sttes, the reltive contriution of functionl limittion to doctor visits nd hospitliztions is higher mong lck nd Ltin people thn mong white people 1. An importnt expression of the socil inequlities in Brzil is the ccess to privte helth plns, which depend on the cpcity of pying 6. Previous reserch showed tht users of the privte system present etter helth nd use more helth-cre services when compred with users of the pulic system 6,7. Our results re in line with these oservtions. The prevlence of functionl limittion ws 28% higher mong users of the pulic system when compred with those of the privte system. In solute terms, pulic system users with nd without functionl limittions performed less doctor visits nd were less hospitlized in comprison to privte system users. Within the sme system, however, our results indicte tht the strength of the ssocitions etween functionl limittion nd numer of doctor visits nd hospitliztions ws similr mong users of ech of these systems. d Ministério d Súde (BR), Secretri de Atenção à Súde, Deprtmento de Ações Progrmátics e Estrtégics, Áre Técnic Súde do Idoso. Atenção à súde d pesso idos e envelhecimento. Brsíli (DF); (Série B. Textos Básicos de Súde; (Série Pctos pel Súde 2006, 12). Due to their form of orgniztion, privte helth insurnces offer more doctor visits with specilists nd its users seek cre predominntly in doctor s offices or privte clinics 8. In contrst, the pulic system offers more doctor visits with generl prctitioners nd the predominnt loction of the demnd for cre is the UBS 8. Our results re consistent with these stndrds nd show tht, regrdless of the helth-cre system (pulic or privte), functionl limittion is not ssocited with the specilty of the physicin nor with the existence of service or professionl of reference. On the other hnd, in the privte system (ut not in the pulic), we oserved greter propensity of older dults with functionl limittions to seek UBS, which is cre unit of the pulic system. The interprettion of this result is not intuitive, since the loction sought for cre depends on severl fctors, mny of which were not included in this nlysis 8,21. A possile explntion is tht the loction next to houses or the primry cre model dopted y these units is more convenient, in the users perception, to the needs of those with functionl limittions d. Our nlysis is limited to exmine the issue, ut this 7s

8 finding clls ttention to the need for deeper investigtions for etter understnding of the needs of helth cre for older dults with functionl limittions. The user s perception out helth cre is n importnt tool for evluting the helth systems 22. In Brzil, popultion-sed studies sed on user s perception out the cre received re still scrce, ecuse until recently there were no ntionwide dt on the topic 8. Our results show tht, in generl, the users evlution of the qulity of medicl cre received ws positive. However, this evlution ws little worse in the pulic system when compred with the privte one, especilly y the lck of freedom for choosing the doctor nd the long witing time, in line with the pttern recently descried for the whole Brzilin dult popultion 8. Our results lso show tht, mong privte system users, the evlution of the seven qulity indictors ws similr mong those with nd without functionl limittion. In the pulic system, only two indictors showed ssocition with functionl limittion freedom for choosing the doctor nd witing time for ppointment. For oth, the prevlence of the evlution of these indictors s good or very good ws lower mong those with functionl limittion (OR < 1.0). The min dvntge of this study is its lrge popultion se, with ntionl representtion. On the other hnd, this study hs limittions inherent to the cross-sectionl nture of the reserch, to the informtion not included in PNS, nd to the provision of dt for nlysis t the time the study ws conducted. In ddition, the functionl limittion in this study included smll difficulty in performing ctivities of dily living, s well s recent studies conducted in other countries 10. Therefore, nlyses sed on the severity of functionl limittion my show even stronger ssocitions thn those oserved in this study. In short, our results showed strong ssocition etween functionl limittion, doctor visits, nd hospitliztions. Due to the rpid ging of the Brzilin popultion, n increse in the numer of older dults with functionl limittions is expected. If effective mesures re not extended to helth promotion nd prevention in their severl levels, the incresed demnd for helth cre will e inevitle, oth for pulic nd privte helth systems. REFERENCES 1. Bowen ME, González HM. Rcil/ethnic differences in the reltionship etween the use of helth cre services nd functionl disility: the Helth nd Retirement Study ( ). Gerontologist. 2008;48(5): Gong CH, Kendig H, He X. Fctors predicting helth services use mong older people in Chin: n nlysis of the Chin Helth nd Retirement Longitudinl Study BMC Helth Serv Res. 2016;16: Wng HH, Shyu YL, Chng HY, Bi YB, Stnwy F, Lin JD, et l. Prevlence, chrcteristics, nd cute cre utiliztion of disled older dults with n sence of help for ctivities of dily living: findings from ntionlly representtive survey. Arch Gerontol Geritr. 2016;67: Trvssos C, Mrtins M. Um revisão sore os conceitos de cesso e utilizção de serviços de súde. Cd Sude Pulic. 2004;20 Supl 2:S Andersen R, Newmn JF. Societl nd individul determinnts of medicl cre utiliztion in the United Sttes. Milnk Mem Fund Q Helth Soc.1973;51(1): Pim J, Trvssos C, Almeid C, Bhi L, Mcinko J. The Brzilin helth system: history, dvnces, nd chllenges. Lncet. 2011;377(9779): Mcinko J, Lim-Cost MF. Access to, use of nd stisfction with helth services mong dults enrolled in Brzil s Fmily Helth Strtegy: evidence from the 2008 Ntionl Household Survey. Trop Med Int Helth. 2012;17(1): Szwrcwld CL, Dmcen GN, Souz Júnior PRB, Almeid WS, Mlt DC. Percepção d populção rsileir sore ssistênci prestd pelo médico. Brsil, Cienc Sude Coletiv. 2016;21(2): s

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