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Abstract
Background Respiratory diseases (RDs) cause millions of hospitalisations and deaths worldwide, resulting in economic and social impacts. Strategies for health promotion and disease prevention based on the epidemiological profile of the population may reduce hospital costs.
Aim To characterise hospitalisations and deaths due to RDs in Brazilian adults above 20 years old between 2008 and 2021.
Methods This ecological study used secondary data of hospitalisations and deaths due to RDs from the Hospital Information System of the Brazilian Unified Health System between 2008 and 2021. Data were grouped according to region, age group and sex. The period was divided into first (2008–2011), second (2012–2015) and third (2016–2019) quadrennia and one biennium (2020–2021), and all data were analysed using the GraphPad Prism; statistical significance was set at p<0.05.
Results A total of 9 502 378 hospitalisations due to RDs were registered between 2008 and 2021. The south and southeast regions presented the highest hospitalisation and fatality rate, respectively, in the age group ≥80 years with no significant differences between sexes. Also, RDs caused 1 170 504 deaths, with a national fatality rate of 12.32%.
Conclusion RDs affected the Brazilian population and impaired the health system, especially the hospital environment. The south/southeast regions were the most affected, and the ageing process contributed to the increased incidence of RDs.
- Clinical Epidemiology
- Respiratory Infection
- Pulmonary Rehabilitation
Data availability statement
Data are available in a public, open access repository.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Respiratory diseases (RDs) are a major public health problem as they achieved 544 899 200 cases worldwide in 2017, increasing by 39.5% compared with 1990.
Although several studies have reported that the number of hospitalisations and deaths has decreased along the last decades, they are still the third leading cause of hospitalisations worldwide.
WHAT THIS STUDY ADDS
To understand the epidemiological profile of hospitalisations and deaths due to RDs according to living region, age group and sex may be helpful in the development of new health promotion and disease prevention strategies.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
By performing a study using a free and reliable platform from the hospital information system of the Unified Health System (SIH/SUS), it is possible to assess the impact of the strategic action plan to combat chronic non-communicable diseases.
Background
Respiratory diseases (RDs) are a combination of genetic, physiological, environmental and behavioural factors that may impair lung function, functionality, quality of life and social interaction.1 Also, they represent a major public health problem, affecting health, economic and social systems.1 Chronic RD achieved 544 899 200 cases worldwide in 2017, increasing by 39.5% compared with 1990.2 Although asthma is the second most prevalent chronic RD worldwide, its incidence has been reduced since 1990.3 In Brazil, chronic RD decreased over the years, and asthma and chronic obstructive pulmonary disease (COPD) presented the highest prevalence among these diseases in 2017.4
Despite the different incidence and prevalence rates worldwide, the incidence of chronic RD was higher for men than women aged >40 years until 2014, whereas the prevalence of COPD and asthma was higher for women than men between 1990 and 2017.2 Also, improved access to health services (eg, vaccination) reduced the incidence and prevalence of chronic RD for all ages and sexes in Brazil in the last 27 years.4 Moreover, a systematic review has shown that vaccination also reduced the prevalence of invasive pneumococcal disease such as pneumonia in Brazil.5
Interstitial lung disease, pulmonary sarcoidosis, pneumoconiosis, exacerbations of COPD, asthma and respiratory infections from several risk factors are responsible for the majority of hospitalisations due to RD worldwide.3 It is important to remember that smoking also appears as an aggravating risk factor for the development of chronic RD and its exacerbations, which ends up culminating in emergency hospitalisation.6 Hospitalisations due to chronic RD in Brazil reduced from 383/100 000 inhabitants in 2000 to 177/100 000 in 2009.7 Moreover, asthma was responsible for 129 728 hospitalisations in 2013,8 and 680 207 individuals aged >20 years were hospitalised due to RD in 2019 in the country.6
RDs were the third leading cause of death (3 914 196 deaths) worldwide in 2017,3 9 increasing by 18% since 1990, mostly due to COPD.3 Deaths from RD increased for all ages and sexes in Brazil between 1990 and 2017.4 Moreover, the monthly mortality rate due to chronic RD was 2.33±0.59 between 1996 and 2017.6 Also, the mortality rate from RD was 40% higher in men than women in Brazil, which may be associated with prevention and early treatment performed by women.4
It is worth highlighting that acute respiratory infections (ARIs) are also responsible for high morbidity and mortality worldwide.10 According to WHO, around three million deaths occurred in 2016 due to ARI.10 Moreover, acute lower respiratory infections, such as pneumonia and bronchiolitis, are the leading cause of hospital admissions and in-hospital deaths in young children.11 In a study performed by Correa et al in 2017 ARIs are the third cause of mortality in the Brazil population.12
Another important cause of hospitalisations and deaths in the last years was SARS-CoV-2. In a study performed by Figueiredo et al,13 the estimated cases in Brazil were nearly 15%.13 Moreover, COVID-19 led to lifestyle changes by reducing physical activity performance and negative effects on healthcare access and curative and preventive quality, increasing the burden of disease and mortality after the epidemic outbreak.14 With the advancement of the COVID-19 pandemic, tuberculosis also gained prominence, increasing the absolute number of deaths, which did not occur in the last decade. This may be explained by the interruption of investments in treating the disease to the detriment of the costs involved in COVID-19.15
Hospitalisations due to RD are costly to the public health system (about 884 million reais).16 In asthma, for example, the increase in family costs with treatment may be directly related to cases that are not under control.16 In addition, clinical manifestations and systemic complications of RD increase the risks of hospitalisation and death.17
New strategies for health promotion and disease prevention (eg, pulmonary rehabilitation) must be developed to reduce hospitalisations and deaths.18 Considering these strategies, the analysis of hospitalisations and deaths according to age, sex and region may help to develop and implement interventions and preventive measures, reducing hospital costs from complications and hospitalisations.19 20 Thus, this study aimed to characterise hospitalisations and deaths caused by RD in Brazilian adults aged >20 years between 2008 and 2021.
Methods
Study design
This ecological study used secondary data regarding hospitalisations and deaths due to RD in the Brazilian population aged >20 years between 2008 and 2021. Data from public and private services registered in the Hospital Information System from the Unified Health System (SIH/SUS) were analysed according to the 10th revision of the International Classification of Diseases.
Ethical aspects
According to Resolution 510/2016 of the Brazilian National Health Council, ethical approval is unnecessary for descriptive studies since data were accessible in the Department of Informatics of SUS (DATASUS).7 Confidentiality was ensured for all individuals.
Data extraction and analysis
Data were extracted from the DATASUS in March 2022 and grouped for statistical analysis according to region, age, sex and period.7 Data regarding costs and length of stay were also collected. The period was divided into first (2008–2011), second (2012–2015) and third (2016–2019) quadrennium and one biennium (2020–2021). The analysis by age and region followed the 2010 census of the Brazilian National Institute of Geography and Statistics (IBGE) (http://ibge.gov.br).
The hospitalisation rate was calculated according to region, sex and age by the ratio between hospitalisations and the Brazilian population estimated from 2000 to 2030 by the IBGE and presented per 100 000 inhabitants. Also, the hospital fatality rate was calculated by the ratio between deaths and hospitalisations registered in the study period multiplied by 100.
Data were plotted into an Excel spreadsheet (Microsoft Office V.2013) and analysed using the GraphPad Prism software (V.5.0). The Kolmogorov-Smirnov verified data normality. Hospitalisations and hospital deaths due to RD were described as absolute and relative frequency. The two-way analysis of variance followed by Bonferroni post hoc compared the study groups. Statistical significance was set at p<0.05.
Results
Hospitalisations due to RD
A total of 9 502 378 hospitalisations due to RD in adults aged >20 years were registered in the public system in Brazil between 2008 and 2021, according to the national database. During the study period, pneumonia was the main cause of hospitalisations (n=5 007 065), followed by other COPDs (including bronchitis/emphysema) (n=1 471 081), other diseases of the respiratory system (n=1 456 281) and asthma (n=643 078). The incidence of hospitalisations due to RD is presented in table 1. The mean length of stay was 4.68±2.79 days. The highest length of stay was due to bronchiectasis (9.4 days) followed by other diseases of the respiratory system (9.1 days). Moreover, the mean hospitalisation cost was 642.5 (403.9–1053) reais per hospitalisation. The highest values are for other diseases of the respiratory system (2.578.8 reais) and bronchiectasis (1.251.7 reais).
Hospitalisation due to RD between 2008 and 2021 in Brazil
Hospitalisations according to Brazilian demographic region
Demographic region presented the following absolute numbers of hospitalisations between 2008 and 2021: southeast, 355 000; south, 2 271 227; northeast, 2 245 404; midwest, 780 182; and north, 655 560.
The south region presented the highest hospitalisation rate (784.6/100 000 inhabitants), followed by midwest (535.5/100 000 inhabitants), north (449.9/100 000 inhabitants), northeast (439.0/100 000 inhabitants) and southeast (418.4/100 000 inhabitants). Figure 1 presents the comparison of hospitalisation rates between regions according to periods.
Hospitalisation rate due to respiratory diseases according to demographic region between 2008 and 2021. Statistical differences between regions: *p<0.05, **p<0.001, ***p<0.0001. Two-way ANOVA followed by Bonferroni post hoc. ANOVA, analysis of variance.
Hospitalisation numbers due to RD were reduced in all regions according to periods. Comparing the first and second quadrennium, all regions showed a reduction in the comparison varying from 2.10% (southeast) to 13.21% (midwest). Considering the second to third quadrennium, the decrease percentage varied from 0.52% (southeast) to 8.37% (north). During the third quadrennium and the biennium, the reduction varied from 56.76% (southeast) to 67.64% (south). The mean hospitalisation rate was slightly reduced in the biennium compared with all quadrennial. However, only the south (p<0.0001) and midwest (p<0.001) regions significantly reduced the hospitalisation rate between the first quadrennium and the biennium. The south region also significantly reduced the hospitalisation rate in the second (p<0.001) and third (p<0.05) quadrennium compared with the biennium.
Hospitalisations according to sex
A total of 4 818 429 (50.7%) hospitalised individuals were males, and 4 683 949 (49.3%) were females. Also, the hospitalisation rate was 510.52/100 000 inhabitants for males and 469.89/100 000 for females.
Although hospitalisation rate significantly reduced for both sexes during the analysed period (p<0.05), no significant difference was observed between sexes (p>0.05). Figure 2 presents the differences between periods according to sex.
Hospitalisation rate due to respiratory diseases according to sex between 2008 and 2021. Statistical difference between periods: *p<0.05, **p<0.001, ***p<0.0001. Two-way ANOVA followed by Bonferroni post hoc. ANOVA, analysis of variance.
Hospitalisations according to age group
The age group ≥80 years presented the highest hospitalisation rate (4033/100 000 inhabitants), followed by 70–79 years (1913/100 000 inhabitants), 60–69 years (883/100 000 inhabitants), 50–59 years (440/100 000 inhabitants), 40–49 years (250/100 000 inhabitants), 30–39 years (178/100 000 inhabitants) and 20–29 years (168/100 000 inhabitants).
When comparing the age groups, the hospitalisation rate of groups between 20 years and 59 years was significantly lower than the ≥70 years. The age groups between 60 years and 79 years also presented lower hospitalisation rate than the group ≥80 years, which presented higher hospitalisation rate than all other age groups. Only the age group ≥80 years presented statistical differences considering the first (p<0.01), second (p<0.05) and third (p<0.01) quadrennia compared with the biennium. Although the mean hospitalisation reduced between periods, the hospitalisation rate increased for individuals aged ≥50 years (table 2).
Hospitalisation and fatality rate due to respiratory diseases according to the age group in Brazil
Hospital deaths due to RD
A total of 1 170 504 hospital deaths due to RD were registered in the public health service for Brazilian individuals aged >20 years from 2008 to 2021. Fatality increased by 46% during the analysed period (2008, 60 226, vs 2021, 87 863). Moreover, most deaths occurred due to pneumonia (56.5%), followed by other diseases of the respiratory system (31.2%) and bronchitis/emphysema (9.5%). The national mean fatality rate during hospitalisations was 12.32. Moreover, the fatality rate was 8.83 in 2008 and 17.48 in 2021.
Hospital deaths and fatality rate according to demographic region
The southeast region presented the highest number of deaths (n=556 958; 47.53%), followed by the south (n=246 213; 20.91%), northeast (n=238 791; 20.47%), midwest (n=74 116; 6.31%) and north (n=54 426; 4.79%). Also, the southeast region presented the highest fatality rate (15.69), followed by the south (10.84), northeast (10.63), midwest (9.54) and north (8.30). The comparison of the hospital fatality rate between regions is presented in figure 3.
Hospital fatality rate due to respiratory diseases according to the region between 2008 and 2021. Statistical difference between regions: *p<0.05, **p<0.001, ***p<0.0001. Two-way ANOVA followed by Bonferroni post hoc. ANOVA, analysis of variance.
The hospital fatality rate gradually increased according to the periods (first quadrennia, 8.19; second quadrennia, 10.76; third quadrennia, 12.62; and biennium, 15.52).
Hospital deaths and fatality rate according to sex
RD caused 623 882 (53.30%) deaths in men and 546 621 (46.70%) in women between 2008 and 2021. The fatality rate was similar for both sexes between 2008 and 2021 (men, 12.95, and women, 11.67; p>0.05). Also, the mean fatality rate gradually increased according to the periods for men (first quadrennium, 10.36; second quadrennium, 12.72; third quadrennium, 14.21; and biennium, 17.25) and women (first quadrennium, 8.81; second quadrennium, 11.45; third quadrennium, 13.18; and biennium, 16.60). The fatality rate was statistically different for both sexes between the first quadrennium and the biennium (p<0.05).
Hospital deaths and fatality rate according to age group
The age group ≥80 years presented the highest number of deaths (35.80%), followed by 70–79 years (25.18%), 60–69 years (17.61%), 50–59 years (10.72%), 40–49 years (5.65%), 30–39 years (3.11%) and 20–29 years (1.93%). Also, the fatality rate gradually increased according to the age group: 20–29 years, 2.92; 30–39 years, 4.68; 40–49 years, 7.29; 50–59 years, 10.06; 60–69 years, 12.97; 70–79 years, 6.17; and ≥80 years, 22.72.
The mean hospital fatality rate gradually increased according to the periods (first quadrennium, 8.61; second quadrennium, 10.21; third quadrennium, 11.05; and biennium, 14.02). In addition, the fatality rate tended to increase in individuals aged ≥50 years; the age group ≥80 years presented the highest value. Differences between age groups and periods are presented in table 2.
Considering the first quadrennium and the biennium, the mean fatality rate was statistically different between the age groups of 60–69 years (p<0.01), 70–79 years (p<0.01) and ≥80 years (p<0.001). Also, the age group of 70–79 years and ≥80 years presented significant differences between the second quadrennium and the biennium (p<0.05). However, all age groups presented no difference between the third quadrennium and the biennium (p>0.05; table 2).
Discussion
This study characterised hospitalisations and deaths registered in SIH/SUS due to RD in Brazilian adults aged >20 years between 2008 and 2021. A total of 9 502 378 hospitalisations due to RD were registered in this period, with the highest incidence due to pneumonia. The highest hospitalisation rate was in the south region and age group ≥80 years, and these rates were similar in both sexes. Most deaths were due to pneumonia; the highest hospital fatality rate was in the southeast region and age group ≥80 years.
Most hospitalisations caused by RD from 2008 to 2021 were due to pneumonia, corroborating with Zhao et al, who also showed pneumonia as the main cause of hospitalisations in both sexes in the last 16 years.21 However, the overall hospitalisations reduced from 2008 to 2021 (26.32%), suggesting improved health promotion, surveillance and comprehensive care, especially with actions for smoking cessation and improved access to health services and medications.6 Studies have shown that the prevalence of smokers in Brazil in 1989 was 34.8% in those aged 18 years or more. Moreover, according to the Protection and Risk Factors for Chronic Diseases by Telephone Inquiry (Vigitel)/2015, this prevalence was reduced to 10.5% in the last decade.22
On the other hand, England presented 1 868 092 hospitalisations due to RD in 2019, an increase of 133.4% in comparison with 1999, and pneumonia was the second cause of hospitalisations (26.4%).23 The increase in hospital admissions in England may be explained by an absolute increase in the population size and life expectancy. In any way, the appropriate diagnosis and early intervention may reduce these numbers.3
The south region presented the highest hospitalisation rate, which may be related to the subtropical climate that increases respiratory infections due to the low temperature during the winter. Recently, some authors found a relation to relative risk (1.07; 95% IC: 1.01 to 1.14) for respiratory hospital admissions with a low temperature in Brazil.24 Also, the reduced hospitalisation rate in all regions from 2008 to 2021 may be related to the beginning of influenza vaccination (1999), even considering the different causes of respiratory infections.25 In addition, this result may occur due to improved health conditions and access to health services.6
The hospitalisation rate was 510.52/100 000 inhabitants for males and 469.89/100 000 for females. The mean hospitalisation according to sex reduced over time in the present study, corroborating Malta et al data (17% for men and 44% for women) from 2000 to 2015.1 Although it is well known that lung volume, size and shape differ between sexes, influencing the distending forces and the recoil pressure of the lung,26 which may lead to the development of RDs, we have not found any difference between sexes.
Considering age groups, individuals aged ≥50 years presented the highest hospitalisation rate, especially those ageing ≥80 years (20.08%). A retrospective study reported similar results for older adults between 2000 and 2015, in which most hospitalisations were caused by RD.6 Another recent Brazilian study, when analysing data from 2013 to 2023, also found a higher hospitalisation rate by RDs in the age group over 60 years.27 Also, the population aged ≥60 years may double by 2060,21 leading to economic and health problems and influencing hospitalisations. Studies have shown that ageing is significantly associated with an increased risk of morbidity and mortality due to RDs as during the ageing process there are changes in lung structures and function.28 In a study performed by Naser et al, the age category 75 years or older showed the fastest hospitalisation admissions rate, which is similar to our findings.23
Deaths caused by RD increased by 46% between 2008 and 2021, mostly due to pneumonia (56.5%) and in the southeast region (47.53%). Also, RD caused more deaths in men than in women in the same period, suggesting that women performed early prevention and treatment.4 The onset of the COVID-19 pandemic in 202029 and the scarcity of ventilatory support in the southeast region30 might be responsible for the increased deaths. In addition, deaths due to pneumonia may be related to increased air pollution by fuels and materials.31
The southeast region presented the highest fatality rate (15.69), possibly due to the demographic transition,32 which was enhanced in the biennium due to the pandemic.29 Considering that the highest fatality rate occurred in the biennium (ie, in the first months of the COVID-19 pandemic), deaths may be due to the severity of the disease, scarcity of beds in the intensive care unit and ventilatory support.29 33 Data from DATASUS showed that in 2021, Brazil registered 14.6 million cases of COVID-19, a higher number than that recorded during the entire year of 2020 (7.68 million)34 which may have influenced the greater number of hospitalisations in the biennium. Additionally, a recent study observed that a burden on the Brazilian health system during the second wave occurred in 2021.35 Moreover, lifestyle changes during the pandemic period may have led to an increase of respiratory exacerbation. Recent studies have shown a worsening of nutritional status and increased physical inactivity in Brazil, accompanied by an even more sedentary lifestyle with increased screen time in Brazil during this period.36–38
The fatality rate for the age group ≥80 years gradually increased, and a similar result was found from 1990 to 2017.1 4 Also, the ageing process impairs the respiratory system, which may increase fatality in older adults.39 The fatality rate between periods 2008 and 2021 was not different between the sexes, which has been observed since 2000.40 However, it gradually increased for both sexes, probably due to the improved notification of the health system throughout the decades.39
It should not be forgotten that air pollution in Brazilian territory over the years may also have influenced the number of hospitalisations. According to several studies, the impact of exposure to a nominal mean aerodynamic diameter ≤10 µm (PM10) is associated with increased hospitalisations due to RD.41 A recent study, which analysed the climate impact in Brazil over 16 years (2003–2018), showed that increased air pollution was associated with more than 6500 deaths.42
This study presented limitations as included data were extracted from SIH/SUS only. In this way, it may not represent the total number of hospitalisations and deaths during the period. Moreover, some data were inadequately registered (eg, incomplete information, error in the disease registration, name, age, sex and period), which may cause losses. Also, rehospitalisations were not detailed since data were not individualised. Although data were secondary and an unknown proportion of hospitalisations and deaths may be lost, they were from the federal government, representing the epidemiological monitoring of the country.
Conclusion
RD caused 9 502 378 hospitalisations from 2008 to 2021 in Brazil according to the government database. The most affected are those living in the south/southeast regions and aged over 50 years as they showed the highest hospitalisation rates. The country also had 1 170 504 deaths during the period. Considering the fatality rate, the same pattern was observed being the southeast region and those aged over 50 years the most affected. It is important to highlight that both hospitalisation and fatality rates increased in the last period of the study which may be explained by the COVID-19 pandemic. Epidemiological studies are important to understand disease pattern and may contribute to the development of new strategies for health promotion and disease prevention (eg, pulmonary rehabilitation and preventive measures) to reduce hospital costs from complications and hospitalisations.
Data availability statement
Data are available in a public, open access repository.
Ethics statements
Patient consent for publication
Ethics approval
In accordance with the Brazilian National Health Council (Resolution No.510 from 7 April 2016), which regulates the National Research Ethics Committee, ethical approval is not required. All data may be accessed at DATASUS (http://datasus.saude.gov.br/ http://datasus.saude.gov.br/).
Acknowledgments
The authors thank Probatus Academic Services for providing scientific language translation, revision and editing.
Footnotes
DAL and LGdAF contributed equally.
Contributors Conceptualisation: DAL, LPG, INDFL. Data curation: DAL, LGdAF, RBF, JABdA. Formal analysis: DAL, LGdAF, LPG. Funding acquisition: DAL, LPG. Investigation: DAL, LGdAF, RBF, JABdA. Methodology: DAL, LGdAF, LPG, INDFL. Project administration: DAL, LPG. Supervision: LPG, INDFL. Visualisation: DAL, LGdAF, RBF, JABdA, LPG, INDFL. Roles/writing, original draft: DAL, LGdAF, RBF, JABdA. Writing, review and editing: DAL, LGdAF, RBF, JABdA, LPG, INDFL, LPG is the guarantor of the work.
Funding This study was partly financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES). Finance Code 001.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability All data are free and accessible to all at SIH/SUS.