Profile of Emergency Service Use in a Brazilian Capital City

Profile of Emergency Service Use in a Brazilian Capital City | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Profile of Emergency Service Use in a Brazilian Capital City Emily de Jesus Fraga, Bárbara Cássia Santana Farias Santos, Mariana Endlich Suave Vaz, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7999517/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background This study aimed to analyze the utilization profile of an emergency department (ED) in a Brazilian capital by identifying patients' sociodemographic characteristics, reasons for seeking care, and the appropriateness of ED use. Methods A cross-sectional study was conducted over 30 consecutive days between November and December 2019. A total of 1,177 users aged 18 or older were interviewed using a structured questionnaire and selected through systematic random sampling. Data were analyzed using Stata 17, estimating prevalence and 95% confidence intervals (95%CI). The Hospital Urgency Appropriateness Protocol (HUAP) was used to assess inappropriate use. Results ED use was more frequent among young adults (57.8%; 95% CI: 54.9–60.6), women (62.4%; 95% CI: 59.5–65.1), mixed race individuals (55.0%; 95% CI: 52.1–57.8), socioeconomic class C (58.4%; 95% CI: 55.5–61.2), those with a high school education (44.7%; 95% CI: 41.9–47.5), without private insurance (87.4%; 95% CI: 85.1–89.4), married (48.2%; 95% CI: 45.3–51.0), and with good self-rated health (44.5%; 95% CI: 41.7–47.4). Most sought care directly (71.7%; 95% CI: 69.0–74.2) and were classified as low-urgency cases (73.0%; 95% CI: 70.4–75.5), although 76.2% (95% CI: 73.6–78.5) perceived their condition as urgent. Additionally, 73.2% (95% CI: 70.6–75.6) stated they would not have visited the ED if they could have had a primary health care (PHC) appointment the following day. Among those perceiving low urgency, 28.7% (95% CI: 23.5–34.4) chose the ED believing it to be more effective. Among those who had sought care elsewhere previously, 53.2% (95% CI: 47.8–58.6) migrated to the ED due to dissatisfaction with PHC. Inappropriate use occurred in 29.3% (95% CI: 26.7–32.1). Conclusion Direct demand for ED services and challenges in primary care highlight the need to strengthen PHC. Improving access to and quality of PHC could reduce unnecessary ED visits, enhance service efficiency, and support a more sustainable healthcare system. Emergency medical services Health services misuse Brazil Background The Brazilian health system consists of a complex network of services, historically built on social movements that sought to ensure universal and comprehensive access to health care [ 1 ]. In this context, urgent and emergency care services play a strategic role as one of the main entry points to the Health System, focused on treating acute and highly serious conditions [ 2 ]. Conceptually, Ordinance n. 354 of 2014 establishes distinctions between the terms urgency and emergency. Emergency refers to the medical observation of worsening health conditions involving intense suffering or imminent risk of death. Urgency, on the other hand, refers to an unforeseen occurrence of health impairment, with or without potential risk to life. Both require immediate assistance [ 3 ]. In Brazil, the "Unidades de Pronto Atendimento (UPAs)" or “Pronto Atendimento (PA)” are emergency care units that are part of this network as intermediate-complexity facilities, operating between primary care and hospitals. Their functions include patient stabilization, the provision of pre-hospital care, the transfer of patients to other medical centers when necessary, as well as providing assistance in low-complexity acute cases when primary care services are not available[ 4 ]. However, the use of these services by patients with minor complaints has become frequent, often due to barriers in accessing other levels of care, especially primary care [ 5 , 6 ]. The literature also points to the belief in the greater effectiveness of the ED, the possibility of tests, immediate medication, and convenience as the main factors for seeking these services [ 7 , 8 , 9 , 10 ]. However, this pattern of use can overload the units, compromise the effectiveness of care, and potentially be detrimental to continuity of care [ 11 , 12 ]. Given this, it is essential to understand the profile of users and the factors that influence the choice of these services in order to support strategies for organizing the network and improving access. This study aims to analyze the profile of users of an emergency department in the city of Vitória (ES), as well as to identify the reasons that motivate the search for this service. Methods This is a cross-sectional study conducted in Vitória, capital of the state of Espírito Santo, Brazil, with the objective of analyzing the profile of users and factors associated with the use of an ED. Data collection was carried out over 30 consecutive days in November and December 2019, with 24-hour coverage. The municipality of Vitória is the capital of the state of Espírito Santo, located in the southeastern region of Brazil, with a population of 322,869 inhabitants [ 13 ]. In 2010, it recorded a Human Development Index (HDI) of 0.845, one of the highest in the country. The municipal health system is computerized, provides extensive coverage under the "Estratégia de Saúde da Família (ESF)" - the country’s primary care model - [ 14 , 15 ], and offers a range of outpatient services. The city has two PAs and an emergency network that operates continuously, 24 hours a day, seven days a week. The study was conducted in only one of these. Care follows the Manchester Protocol for risk classification [ 16 ] and covers clinical care for adults and children, low complexity emergency care, minor surgical procedures, and emergency dental services. Because it is located in a metropolitan area, Vitória receives an intense flow of people from neighboring municipalities, especially during business hours. The sample size was calculated based on an estimated prevalence of 24.2%, as obtained in Carret et al. (2009), in a study that used the same protocol to measure the inappropriate use of emergency services. A margin of error of ± 2.5 percentage points and a confidence level of 95% were considered. Incorporating 10% for possible losses and/or refusals, the required sample size was estimated at 1,219 individuals. At the end of the collection, the sample reached 1,177 individuals. Individuals aged 18 years or older who were admitted to the ED and underwent the risk classification process were recruited. Individuals escorted by police officers, as well as those who sought the service to obtain medication or for administrative reasons, were excluded from the study. Participants were selected by systematic random sampling. Inside the clinical risk stratification room, the first participant was chosen at random, and after this initial selection, one in every 11 individuals was included, ensuring a systematic and consistent process. The interviews were conducted in the emergency room using a structured questionnaire that addressed sociodemographic information, the reason for the visit to the ED, medical history, self-perceived health, and comorbidities. The interviews were conducted by a trained team, all over the age of 18 and under supervision. The variables analyzed included sex (female/male), skin color (white/black/Mixed-Race/indigenous-asian), years (18–39 years/39–59 years/60 years or older), marital status (married/single/separated/widowed), Level of education (None and Incomplete Fundamental school/Fundamental school/Middle school /Graduation and Postgraduate Studies), economic status by Brazilian Economic Classification Criteria (Brazilian Criteria) – ABEP, Possession of private health insurance or a discount card (No / Discount card / Private health insurance), self-assessment of health (very poor-poor/Fair/Good-Excellent), multimorbidity (Yes/No), sought care elsewhere (No/Yes), Where did you seek care first (PHC unit/Emergency care unit/Private hospital emergency room/Private practice ), Did you get care on your first try? (No/Yes), Why weren't you seen on this first attempt? ( Could not get an appointment/No doctor available/No professional available/Waited and gave up/It wasn’t working/Couldn’t afford it), self-perceived need (Yes/No), has a reference primary health clinic (Yes/No), presence of a reference physician or nurse (Yes/No), Why didn't you see a doctor/nurse today ( The place where he or she works was closed/My case is ED/ He couldn't see me/He referred me to the ED/Other), day of visit (Monday to Friday/ Saturday and Sunday ), time of visit (6 p.m.-6 a.m./7 a.m.-5 p.m.), How did you get to this ED? (Walking-Bus/Car-Taxi/Ambulance/Other), use of the ED in the last year(None/1–2 times/3–4 times/5 or more times), Inappropriate use of Emergency Care Unit (Yes/No), risk stratification - Manchester Protocol ( green and blue/yellow/ orange and red), self-perceived urgency (Yes/No) and If it's not serious, why did you come to the ED? (The ED is better equipped to handle it/ Possibility of undergoing tests at the time of consultation/Possibility of receiving medication / Unable to make an appointment at the Health Unit/Health unit only operates during working hours) - this variable was treated as a multiple-response variable, as participants could select more than one reason. The assessment of the self-perceived urgency of the health condition by the individual was carried out by asking the question: “Do you consider your problem to be very serious and requiring immediate attention?”. The self-perceived need to go to the emergency room was investigated with the following question: “If it were possible to easily obtain care from a competent health professional at the primary care center closest to your home or work (where you are registered/referred), would you have come here?” Multimorbidity, defined as the simultaneous presence of two or more chronic diseases, was determined based on the coexistence of the following self-reported health conditions: asthma, osteoporosis, arthritis, hypertension, diabetes, heart disease, pulmonary emphysema, or COPD, Parkinson's disease, renal failure, prostate diseases, thyroid disorders, glaucoma, cataracts, Alzheimer's disease, urinary or fecal incontinence, angina, stroke, high cholesterol, epilepsy, depression, urinary tract infection, and cancer. Inappropriate use was assessed using the Hospital Urgency Appropriateness Protocol (HUAP) [ 18 ], a validated instrument in Brazil [ 19 ] to identify misuse of emergency services, based on five criteria: severity, treatment requirements, diagnostic intensity, need for observation and/or prolonged transfer, and self-referral. Inappropriate use was defined as not meeting any of the 28 criteria evaluated by the HUAP. The research team, with access to the patient's medical records and support from the doctor on duty, completed the criteria after the consultation. Prevalence rates were estimated with 95% confidence intervals (95% CI). Data analysis was performed using StataSE version 17.0 software. In order to facilitate interpretation, we chose to present the data referring to both the total sample of users and the residents of Vitória in a table. However, the discussion will focus on the data from the general sample. Results [Insert Table 1 here.] Table 1 Sample description of the use of the Emergency Care Unit. Vitória, Brazil, 2019. Vitória* (n = 915) Total** (n = 1,177) Variables (n*= 912; n**= 1.174) n % (95% CI) n % (95% CI) Sex Female 565 62.0 (58.7–65.1) 732 62.4 (59.5–65.1) Male 347 38.1 (34.9–42.3) 442 37.6 (34.9–40.5) Skin color (n*=911; n**=1.168) White 198 21.7 (19.2–24.5) 256 21.9 (19.6–24.4) Black 199 21.8 (19.3–24.6) 244 20.9 (18.7–23.3) Mixed-Race 495 54.3 (51.1–57.6) 642 55.0 (52.1–57.8) Indigenous/Asian 19 2.1 (1.3–3.2) 26 2.2 (1.5–3.3) Years (n*=911; n**= 1.173) 18–39 years 530 58.2 (54.9–61.3) 678 57.8 (54.9–60.6) 40–59 years 252 27.7 (24.8–30.7) 333 28.4 (25.9–31.0) 60 or older years 129 14.2 (12.0-16.6) 162 13.8 (12.0–15.9) Marital status (n*= 912 n**= 1.173) Married 433 47.5 (44.2–50.7) 565 48.2 (45.3–51.0) Single 340 37.3 (34.2–40.5) 439 37.4 (34.7–40.2) Separated/divorced 97 10.6 (8.8–12.8) 119 10.1 (8.5–12.0) Widowed 42 4.6 (3.4–6.2) 50 4.3 (3.2–5.6) Level of education (n*=915; n**=1.177) None and Incomplete Fundamental school (0 to 7 years) 155 16.9 (14.6–19.5) 202 17.2 (15.1–19.4) Fundamental school (8 to 10 years) 184 20.1 (17.6–22.8) 222 18.9 (16.7–21.2) Middle school (11 to 14 years old) 396 43.3 (40.1–46.5) 526 44.7 (41.9–47.5) Graduation and Postgraduate Studies (15 years or older) 180 19.7 (17.2–22.4) 227 19.3 (17.1–21.6) Economic Status (ABEP) (n*=910; n**= 1.165) A - B 261 28.7 (25.8–31.7) 338 29 (26.5–31.7) C 535 58.8 (55.6–62.0) 680 58.4 (55.5–61.2) D - E 114 12.5 (10.5–14.8) 147 12.6 (10.8–14.7) Possession of private health insurance or a discount card (n*= 907; n**= 1,166) No 799 88.1 (85.8–90.0) 1020 87.4 (85.1–89.4) Discount card 38 4.2 (3.1–5.7) 51 4.4 (3.3–5.7) Private Health insurance 70 7.7 (6.1–9.6) 95 8.2 (6,7- 9,9) Self-assessment of health (n*=910; n**= 1.172) Very poor - Poor 173 19.0 (16.6–21.7) 237 20.2 (18.0–22.6) Fair 314 34.5 (31.5–37.7) 413 35.2 (32.6–38.0) Good - Excellent 423 46.5 (43.3–49.7) 522 44.5 (41.7–47.4) Multimorbidity (n*=902; n**= 1.162) Yes 411 45.6 (42.3–48.8) 529 45.5 (42.7–48.4) No 491 54.4 (51.2–57.7) 633 54.5 (51.6–57.3) *:Sample of residents of Vitória; **:Total study sample; CI: Confidence interval 95%; ABEP: Brazilian Economic Classification Criteria Of the 1,232 eligible individuals invited, 1,177 (94.5%) agreed to participate in the study. The sample consisted mainly of females (62.4%; 95% CI 59.5–65.1), young adults ( 57.8%; 95% CI 54.9–60.6), self-declared Mixed-Race (55%; 95% CI 52.1–57.8), married (48.2; 95% CI 45.3–51.0), with average schooling (44.7%; 95% CI 41.9–47.5), belonging to economic class C (58.4; 95% CI 55.5–61.2), without private health insurance (86.7%; 95% CI 84.7–88.6), who assess their health status as satisfactory (44.5; 95% CI 41.7–47.4). A significant number of people have multimorbidity (45.5%; 95% CI 42.7–48.4) (Table 1 ). It was observed that 77.7% (915) of respondents were residents of Vitória, while 22.3% (262) resided in other municipalities but sought care at the municipality's emergency department. The sociodemographic profile of non-residents was similar to that of residents, with a predominance of females, young adults, self-declared black or mixed-race, belonging to economic class C, without health insurance, and with a positive assessment of their health status. [Insert Table 2 here.] Table 2 Characteristics of access to emergency care in the sample. Vitória, Brazil, 2019 Vitória * Total ** Variable n % (95% CI) n % (95% CI) Sought care elsewhere (n*= 913; n**= 1.173) Yes 253 27.7 (24.9–30.7) 332 28.3 (25.8–30.9) No 660 72.3 (69.3–75.1) 841 71.7 (69.0–74.2) Where did you seek care first? (n*=250 ; n**=328 ) PHC unit 157 62.6 (56.4–68.3) 175 53.2 (47.8–58.6) Emergency care unit 52 20.8 (16.2–26.3 87 26.5 (22.0–31.6) Private hospital emergency room 10 4.0 (2.2–7.3) 13 4.0 (2.3–6.7) Private practice 9 3.6 (1.9–6.8) 13 4.0 (2.3–6.7) Other services 20 8.0 (5.2–12.1) 28 8.5 (6.0 - 12.1) Did you get care on your first try? (n*=249; n**=327) Yes 167 67.1 (61.0–72.6) 221 67.6 (62.3–72.5) No 82 32.9 (27.4–39.0) 106 32.4 (27.5–37.7) Why weren't you seen on this first attempt? (n*=80; n**=103 ) Could not get an appointment 29 36.3 (26.4–47.5) 32 31.1 (22.8–40.7) No doctor available 9 11.3 (5.9–20.4) 13 12.6 (7.4–20.6) No professional available 9 11.3 (5.9–20.4) 13 12.6 (7.4–20.6) Waited and gave up 15 18.8 (11.5–29.0) 19 18.5 (12.0–27.2) It wasn’t working 4 5.0 (1.9–12.7) 4 3.9 (1.4–10.0) Couldn’t afford it 1 1.3 (0.17–8.6) 1 1.0 (0.1–6.7) other 13 16.3 (9.6–26.2) 21 20.4 (13.6–29.4) self-perceived need Yes 235 25.8 (23.1–28.8) 313 26.8 (24.4–29.4) No 675 74.2 (71.2–76.9) 854 73.2 (70.6–75.6) Reference PHC clinic (n*= 914; n**=1.176) Yes 709 77.6 (74.7–80.2) 849 72.2 (69.6–74.7) No 205 22.4 (19.8–25.3) 327 27.8 (25.3–30.4) Family physician and nurse reference (n*= 914; n**=1.176) Yes 277 30.3 (27.4–33.4) 321 27.3 (24.8–29.9) No 637 69.7 (66.6–72.6) 855 72.7 (70.1–75.2) Why didn't you see a doctor/nurse today? (n*=271; n**= 310) The place where he/she works was closed 69 25.1 (20.3–30.6) 75 23.7 (19.3–28.8) My case is ED 51 18.6 (14.4–23.6) 58 18.4 (14.4–23.0) He couldn't see me 35 12.7 (9.3–17.2) 41 13.0 (9.7–17.2) He referred me to the ED 22 8.0 (5.3–11.9) 25 7.9 (5.4–11.5) Other 94 34.2 (28.8–40.0) 111 35.1 (30.0–40.6) Day of visit (n*= 910; n**=1.170) Mo - Fr 685 75.3 (72.4–78.0) 877 75.0 (72.4–77.4) Sat - Sun 225 24.7 (22.0–27.6) 293 25.0 (22.6–27.6) Time of visit (n*=912; n**= 1.169) 6 p.m - 6 a.m. 328 36.0 (32.9–39.1) 416 35.6 (32.9–38.4) 7 a.m − 5 p.m. 584 64.0 (60.9–67.1) 753 64.4 (61.6–67.1) How did you get to this ED? (n*= 912; n**= 1.174) Walking/bus 367 40.2 (37.1–43.5) 468 39.9 (37.1–42.7) Taxi/Car 484 53.1 (49.8–56.3) 630 53.7 (50.8–56.5) Ambulance 9 1.0 (0.5–1.9) 15 1.3 (0.8–2.1) Other 52 5.7 (4.4–7.4) 61 5.2 (4.1–6.6) Use of the ED in the last year (n*= 894; n**=1.155) None 166 18.6 (16.2–21.3) 205 17.7 (15.6–20.1) 1–2 314 35.1 (32.1–38.3) 418 36.2 (33.5–39.0) 3–4 207 23.2 (20.5–26) 265 22.9 (20.6–25.5) 5 or more times 207 23.2 (20.5–26) 267 23.1 (20.8–25.6) Inappropriate use of Emergency Care Unit (n*= 858; n**=1.098) Yes 257 30.0 (27.0–33.1) 322 29.3 (26.7–32.1) No 601 70.1 (66.9–73.0) 776 70.7 (67.9–73.3) *:Sample of residents of Vitória; **:Total study sample; CI: Confidence interval 95%; PHC: Primary health care; ED: Emergence department. Most respondents sought care directly at the emergency department (71.7%; 95% CI: 69.0–74.2). However, in their self-assessment of need, only 26.8% (95% CI: 24.4–29.4) considered emergency care to be truly necessary. Among those who sought care before going to the ED, 67.6% (95% CI: 62.3–72.5) received care, and the main place they sought care was the PHC unit (53.2%; 95% CI: 47.8–58.6). On the other hand, among those who were not treated on this first attempt (32.4%; 95% CI: 27.5–37.7), the main reason reported was the lack of vacancies (31.1%; 95% CI: 22.8–40.7) (Table 2 ). In addition, 72.7% (95% CI: 70.1–75.2) of ED users reported not having a primary care physician or nurse, however, 72.2% (95% CI: 69.6–74.7) reported having a primary care unit. Among those who stated that they had a referral professional, the main reason for not seeking them was that the facility was closed at the time of the search (23.7%; 95% CI: 19.3– 28.8) (Table 2 ).Care was mainly provided on weekdays (75.0%; 95% CI: 72.4–77.4) and during PHC opening hours (64.4%; 95% CI: 61.6–67.1). The main means of transportation to the ED was taxi or private car (53.7%; 95% CI: 50.8–56.5). Most had used the ED one or more times in the past 12 months (82.3%; 95% CI: 79.9–84.4), and a significant proportion made inappropriate use of the service (29.3%; 95% CI: 26.7–32.1) (Table 2 ). Table 3 Urgency of Care. Vitória, Brazil, 2019 . Vitória Total Variables n % (95% CI) n % (95% CI) riskstratification-Manchester Protocol (n*=914; n**=1.175) Green and blue 668 73.1 (70.1–75.9) 858 73.0 (70.4–75.5) Yellow 208 22.76 (20.2–25.6) 269 22.9 (20.6–25.4) Red and Orange 38 4.2 (3.03–5.7) 48 4.1 (3.1–5.4) Self-perceived urgency (n*=912; n**=1.171) Yes 683 74.9 (72.0–77.6) 892 76.2 (73.6–78.5) No 229 25.1 (22.4–28.0) 279 23.8 (21.5–26.4) If it's not serious, why did you come to the ED? (n*= 216; n**= 265) The ED is better equipped to handle it 58 26.9 (21.3–33.2) 76 28.7 (23.5–34.4) Possibility of undergoing tests at the time of consultation 32 15.0 (10.8–20.5) 38 14.5 (10.7–19.3) Possibility of receiving medication 35 16.4 (12.0–22.1) 44 16.8 (12.7–21.8) Unable to make an appointment at the Health Unit 29 13.6 (9.6–18.9) 32 12.2 ( 8.8–16.8) Health unit only operates during working hours 25 11.7 (8.0–16.8) 29 11.1 (7.8–15.5) Other 140 65.1 (58,5–71,2) 171 64.8 (58.8–70.3) *:Sample of residents of Vitória; **:Total study sample; CI: Confidence interval 95%; ‘If it's not serious, why did you come to the ED?’ is a multiple-response variable. Regarding severity, most users perceived their condition as urgent (76.2%; 95% CI: 73.6– 78.5), despite most of them being classified as non-urgent or slightly urgent cases (73.0%; 95% CI: 70.4–75.5). Among those who did not consider the problem serious (23.8%; 95% CI: 21.5–26.4), the most frequently cited reason for seeking emergency care was the belief that the service is more effective (28.7%; 95% CI: 23.5–34.0) (Table 3 ). Discussion The data from 1,177 participants allowed us to characterize the profile of ED users and identify the reasons for seeking this level of care. The sample consisted mainly of young adults, female, self-declared Mixed-Race, socioeconomic class C, with complete high school education, without health insurance, who rated their health status as good or excellent. Almost half had multimorbidity, most sought ED care directly, and were classified as non-urgent. Approximately one-third made inappropriate use of the service, according to the HUAP protocol. The predominance of women and young people in the use of emergency services was observed in different Brazilian national studies, both with similar methodologies [ 6 , 20 ] and with secondary data [ 21 , 22 , 23 ]. The higher proportion of users classified as low risk by service protocols was also consistent [ 6 , 20 , 21 , 23 ]. The absence of private health insurance and positive self-assessment of health status were consistent with the findings of studies conducted in Piracicaba (SP) and Pelotas (RS), Brazil [ 6 , 24 ]. However, the results regarding education and skin color differed. In this study, most users had between 11 and 14 years of schooling and self-identified as mixed-race, while other studies pointed to a predominance of elementary school education and white people [ 6 , 24 ]. The reality of Vitória, which has one of the highest Human Development Index (HDI) ratings in the country [ 13 ], may contribute to the higher educational level observed in the sample analyzed. With regard to the color/race variable, it is necessary to consider that the southern region of Brazil, where one of the studies with divergent results was conducted, has the highest proportion of self-declared white people in Brazil [ 25 ]. At the same time, recent studies point to a significant increase in the self-declaration of black and mixed-race people at the national level [ 25 , 26 ], which may reflect changes in racial self-perception and influence the results found in this study. It should also be noted that the race/color variable is complex, influenced by sociocultural and historical factors and by the subjective experiences of individuals [ 27 ]. However, it is observed that, although the sample has a higher proportion of individuals with complete high school education and self-declared mixed-race, when compared to the demographic profile of the general population of Vitória [ 13 ], the ED was proportionally more used by people with elementary school education, in line with findings from studies conducted in other locations [ 6 , 24 ] and by self-declared black individuals, which reinforces the divergence observed regarding the race/color variable. Regarding clinical conditions, almost half of the users had multimorbidity (two or more chronic diseases), a proportion about 1.5 times higher than the national average [ 28 ]. Individuals with multiple chronic diseases tend to use emergency services at least twice as often as those without such conditions [ 28 , 29 ]. In addition, more than 80% of respondents had used the emergency department in the last year, with almost half considered frequent users, a criterion associated with financial and operational overload for services [ 30 , 31 ]. Another relevant finding was the discrepancy between users' perceptions and risk classification: more than 76% believed that the problem was serious, although 73% were assessed as low-risk cases by the Manchester protocol. The literature points out that self perception of severity is a determining factor in the choice of service [ 7 , 8 , 32 ], and anxiety in the face of uncertainty about symptoms, as well as previous negative experiences, contribute to the overestimation of this severity [ 32 ]. Additionally, although most cases were classified as low risk, a considerably smaller proportion was identified as inappropriate use according to the HUAP protocol, showing that low risk classification does not necessarily equate to inappropriate use of this equipment. Furthermore, the prevalence is similar to that recorded in Pelotas (RS), with 24.2% [ 33 ], but almost half that identified in Ouro Preto (MG) by the same protocol [ 20 ], indicating that organizational and cultural factors may influence estimates of inappropriate use of emergency services. The findings also suggest weaknesses in primary care. Although most respondents have a PHC unit in their territory, more than 70% stated that they do not have a referral doctor or nurse. Among those who did have one, the main reason for not seeking this professional was that the service location was closed, which could possibly be resolved by extending the opening hours of PHC [ 34 , 35 ]. However, it is important to note that most visits to the emergency department occurred on weekdays and during PHC opening hours, which indicates that, although opening hours may be a relevant factor, they are not the only or main determinant in the choice. The perception of greater effectiveness in emergency services, identified in this study, coupled with the belief that PHC lacks the resources to adequately address certain health problems, seems to be a strong influence on the choice of the ED by users in non-urgent situations, as also demonstrated in qualitative research with this same population [ 10 ]. Evidence suggests that timely access to PHC, especially when same-day care is available [ 36 ] or within two business days [ 37 ], is associated with a reduction in emergency room visits for non-emergency demands [ 36 , 37 ]. In this context, initiatives such as Advanced Access (AA) have been studied as alternatives to balance supply and demand in PHC. The model, initially proposed in the United States in the 1990s and progressively adopted in countries such as England, Canada, Brazil, and Australia, proposes care within 48 hours of the request, regardless of the nature of the problem [ 38 , 39 ]. Brazilian experiences have shown improvement in access and performance indicators after its implementation, in addition to a reduction of almost 10% in secondary referral care [ 40 ]. However, there is still little evidence of its impact on the use of emergency care units in the country, and the modality is not characterized as emergency care, as it requires prior scheduling [ 41 ]. The pattern of direct demand for emergency care has been identified in other Brazilian municipalities [ 17 , 20 ]. On the other hand, about 15% of our interviewees reported having sought care at the PHC before going to the ED, a result similar to that found in a review that pointed out that 13% of self-reported individuals resorted to the emergency room due to difficulty in accessing primary care [ 42 ]. In several countries, it has been found that low accessibility to PHC increases the demand for emergency services, while the link with a referral physician reduces this demand [ 43 ]. In Brazil, an association has been found between the coverage of the ESF and a reduction in the use of emergency services. [ 5 , 28 ]. The local context also needs to be considered. Vitória receives an intense flow of workers from neighboring municipalities, especially in the region where the ED is located, close to commercial areas. The geographical proximity of home or workplace influences the choice of health service [ 34 , 44 ]. Thus, the difficulty of PHC units in meeting demands outside their coverage area may contribute to the demand for emergency services, even in cases of low severity. In summary, the results reinforce that the search for emergency care stems from multiple factors: sociodemographic characteristics, multimorbidity, perception of severity, lack of connection with PHC professionals, and organizational issues. The expectation that users will make conscious and appropriate choices between different levels of health care is unrealistic, since sometimes the service considered ideal from a technical point of view does not correspond to the expectations, perceived needs, or reality experienced by these individuals. Evidence suggests that building a comprehensive, accessible PHC that provides timely care is more likely to attract users and establish itself as the preferred point of entry, potentially alleviating the burden on emergency services. Despite the valuable insights provided by this cross-sectional study, it also has inherent limitations. The absence of an established causal relationship and the presence of temporal ambiguity limit the possibility of drawing definitive conclusions about the relationships between variables. The results may also have been influenced by biases, as the interviews were conducted in the waiting room of the Emergency Care Unit, which may have affected participants' responses due to the context of waiting for care. Furthermore, the study sample may not correspond to all users of emergency care services, since companions and/or patients in serious condition may not have been able to participate in the interviews, which excludes an important part of the population served in the emergency room. Considering the socioeconomic, environmental, and healthcare structure differences between communities, the generalization of the information in this study to other Brazilian regions or other countries should be done with caution. Conclusion The findings reveal that among ED users, the service is often used as the first option for accessing the Health System, with most choosing to seek care directly at the facility, even when PHC are in operation. Among those who sought prior care, more than 50% reported unsatisfactory experiences with the PHC, indicating that the failures in primary care are not only due to limited opening hours during the week, but mainly to the unavailability of the services offered. Thus, although the expansion of the number of establishments is relevant, it is equally crucial to reassess the logic of care so that it aligns with the needs of the population, ensuring compliance with the principles and guidelines of the “ Sistema Unico de Saúde (SUS) ”- The Brazilian healthcare system. Abbreviations ED Emergency Department HUAP Hospital Urgency Appropriateness Protocol PHC Primary Health Care UPA Unidade de Pronto Atendimento PA Pronto Atendimento ES Espírito Santo HDI Human Development Index IBGE Brazilian Institute of Geography and Statistics ESF Estratégia de saúde da família ABEP Brazilian Economic Classification Criteria (Brazilian Criteria) COPD Chronic Obstructive Pulmonary Disease SP São Paulo RS Rio Grande do Sul MG Minas Gerais AA Advanced Access SUS Sistema Único de Saúde Declarations Ethics approval and consent to participate The project was approved by the Medical School Ethics Committee of the Federal University of Espírito Santo (Certificate of Presentation of Ethical Appreciation-CAAE: 13990719.4.0000.5060), and all participants signed the informed consent form. All procedures were conducted in accordance with the Declaration of Helsinki and Resolution No. 466/2012 of the Brazilian National Committee of Ethics in Research (CONEP). Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This research was funded by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and the Fundação de Amparo à Pesquisa e Inovação do Espírito Santo (FAPES), through Call No. 07/2020 – Capixaba Postgraduate Excellence Support Program (PROAPEX). Authors' contributions E.J.F performed data analysis interpretation and drafted the manuscript. L.F.F contributed to data curation, to the drafting and reviewed the manuscript. B. C. S.F.S ; M.E.S.V; R.B.E; T.D.A; A.P.S.C.A contributed to the drafting and reviewed the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. Authors' information EJF, BCSFS, MESV e RBE are postgraduate students at the Federal University of Espírito Santo, Vitória, Brazil. LFF, TDS and APSCA are professors in the Department of Collective Health, Federal University of Espírito Santo, Vitória, Brazil. Authors and Affiliations Federal University of Espírito Santo, Vitória, Brazil Emily de jesus Fraga, Bárbara Cássia de Santana Farias Santos, Mariana Endlich Suave Vaz, Raissa Bamberg Elauar, Leonardo Ferreira Fontenelle, Thiago Dias Sarti e Ana Paula Santana Coelho Almeida References Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011;377(9779):1778–97. [cited 2024 Jul 10]. Available from: https://repositorio.ufba.br/bitstream/ri/3028/1/Per%20int%202011.12.pdf Sousa KHJF, Damasceno CKCS, Almeida CAPL, Magalhães JM, Ferreira MDA. Humanização nos serviços de urgência e emergência: contribuições para o cuidado de enfermagem. Rev Gaúcha Enferm. 2019;40:e20180263. [cited 2024 Jul 15]. Available from: https://doi.org/10.1590/1983-1447.2019.20180263 Brasil. Ministério da Saúde. Portaria nº 354, de 10 de março de 2014., Define diretrizes para implantação do componente Unidade de Pronto Atendimento (UPA 24h) e do conjunto de serviços de urgência 24 horas da Rede de Atenção às Urgências. Diário Oficial da União. 2014 mar 11;48(Seção 1):58–9. [cited 2024 Jul 18]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/prt0354_10_03_2014.html Brasil. Ministério da Saúde. Política Nacional de Atenção às Urgências. 3ª ed. Brasília: Ministério da Saúde; 2013. [cited 2024 Jul 21]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_urgencias_3ed.pdf Dourado I, Medina MG, Aquino R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). Int J Equity Health. 2016;15(1):151. [cited 2024 Aug 01]. Available from: https://doi.org/10.1186/s12939-016-0440-7 Souza LCD, Ambrosano GMB, Moraes KL, Fonseca EPD, Mialhe FL. Fatores associados ao uso não urgente de unidades de pronto atendimento: uma abordagem multinível. Cad Saúde Coletiva . 2020;28(1):56–65. [cited 2024 Aug 05]. Available from: https://doi.org/10.1590/1414-462X202000280354 Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med . 2017;24(9):1137–49. [cited 2024 Aug 08]. Available from: https://doi.org/10.1111/acem.13220 Unwin M, Kinsman L, Rigby S. Why are we waiting? Patients’ perspectives for accessing emergency department services with non-urgent complaints. Int Emerg Nurs . 2016;29:3–8. [cited 2024 Aug 12]. Available from: https://doi.org/10.1016/j.ienj.2016.09.003 McIntyre A, Janzen S, Shepherd L, Kerr M, Booth R. An integrative review of adult patient-reported reasons for non-urgent use of the emergency department. BMC Nurs . 2023;22(1):85. [cited 2025 Jan 19]. Available from: https://doi.org/10.1186/s12912-023-01251-7 Rodrigues MM, Sarti TD, Almeida APSC, Fontenelle LF, Lazarini WS. Uso de serviço de emergência por motivos não urgentes: estudo qualitativo com usuários de um pronto atendimento, Vitória ES, Brasil. 2019. Interface Comun Saúde Educ . 2024;28:e230493. [cited 2025 Apr 02]. Available from: https://doi.org/10.1590/interface.230493 Baratieri T, Lentsck MH, Corona LP, Almeida KPD, Kluthcovsky ACGC, Natal S. Fatores associados ao uso inapropriado do pronto atendimento. Ciênc Saúde Coletiva . 2021;26(6):2281–90. [cited 2024 Sep 02]. Available from: https://doi.org/10.1590/1413-81232021266.18532019 Kanzaria HK, Niedzwiecki M, Cawley CL, Chapman C, Sabbagh SH, Riggs E et al. Frequent emergency department users: focusing solely on medical utilization misses the whole person. Health Aff (Millwood) . 2019;38(11):1866–75. [cited 2024 Sep 10] Available from: https://doi.org/10.1377/hlthaff.2019.00082 Censo. 2022 [Internet]. 2022. [cited 2025 Jan 06] Available from: https://censo2022.ibge.gov.br/panorama/ Barcelos MRB, Cohen SC, Brandão MRA, Cruz SCS, Zandonade E, Figueiredo TAM, Lima RDC. A trajetória da Estratégia de Saúde da Família no município de Vitória, ES. Rev Bras Pesq Saúde . 2013;15(4). [cited 2025 Jun 14] Available from: https://periodicos.ufes.br/rbps/article/view/7602 Mendonça MHM, Martins MIC, Giovanella L, Escorel S. Desafios para gestão do trabalho a partir de experiências exitosas de expansão da Estratégia de Saúde da Família. Ciênc Saúde Coletiva . 2010;15:2355–65. [cited 2024 Sep 03]. Available from: https://www.scielosp.org/pdf/csc/2010.v15n5/2355-2365/pt Rezende MRM, Ercole FF, Matos SS, Donoso MTV. Manchester Protocol at a school hospital emergency service. Rev Rene . 2016 Nov-Dec;17(6):843–9. [cited 2025 Jun 14]. Available from: https://hdl.handle.net/1843/66482 Carret MLV, Fassa ACG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica . 2009;25:7–28. [cited 2024 Sep 20] Available from: https://doi.org/10.1590/S0102-311X2009000100002 Selva TS et al. Validez del protocolo de adecuación de urgencias hospitalarias. Rev Esp Salud Publica . 1999;73:461–75. [cited 2025 Jun 14]. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1135-57271999000400004&lng=e Oliveira RKCD, Santos AMRD, Nolêto JDS, Sá GGDM, Machado RDS, Gouveia MTDO, Madeira MZDA. Hospital emergency suitability protocol: translation and adaptation to the Brazilian culture. Rev Gaúcha Enferm . 2022;43:e20210183. [cited 2025 Mar 06]. Available from: https://doi.org/10.1590/1983-1447.2022.20210183.en Machado GVC, Oliveira FLPD, Barbosa HAL, Giatti L, Bonolo PDF. Fatores associados à utilização de um serviço de urgência/emergência, Preto O. 2012. Cad Saúde Coletiva . 2015;23(4):416–24. [cited 2024 Nov 22]. Available from: https://doi.org/10.1590/1414-462X201500040177 Brito Santos P, Santos TPV, dos Santos PRA. Perfil dos usuários e motivos de atendimentos em serviços não hospitalares fixos de urgência e emergência. Rev Eletr Acervo Saúde . 2021;13(2):e6105. [cited 2025 Feb 15]. Available from: https://doi.org/10.25248/reas.e6105.2021 Garcia VM, Reis RK. Perfil de usuários atendidos em uma unidade não hospitalar de urgência. Rev Bras Enferm . 2014;67(2):261–7. [cited 2024 Oct 25]. Available from: https://doi.org/10.5935/0034-7167.20140035 Veloso IAM, Tibães HBB. Perfil de usuários atendidos em um pronto atendimento de saúde. Rev Recien-Rev Cient Enferm . 2022;12(38):157–64. [cited 2025 Feb 28]. Available from: https://www.recien.com.br/index.php/Recien/article/view/644 Carret MLV, Fassa AG, Paniz VMV, Soares PC. Características da demanda do serviço de saúde de emergência no Sul do Brasil. Ciênc Saúde Coletiva . 2011;16:1069–79. [cited 2024 Sep 18]. Available from: https://doi.org/10.1590/S1413-81232011000700039 IBGE. Censo 2022: pela primeira vez, desde 1991, a maior parte da população do Brasil se declara parda. Agência de Notícias IBGE . 22 dez 2023. [cited 2025 Sep 16]. Available from: https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/38719-censo-2022-pela-primeira-vez-desde-1991-a-maior-parte-da-populacao-do-brasil-se-declara-parda Szwarcwald CL, Stopa SR, Damacena GN, Almeida WDSD, Souza Júnior PRBD, Vieira MLFP et al. Mudanças no padrão de utilização de serviços de saúde no Brasil entre 2013 e 2019. Ciênc Saúde Coletiva . 2021;26:2515–28. [cited 2025 Feb 03]. Available from: https://doi.org/10.1590/1413-81232021266.1.43482020 Muniz JO. Sobre o uso da variável raça-cor em estudos quantitativos. Rev Sociol Polit . 2010;18:277–91. [cited 2024 Aug 27]. Available from: https://doi.org/10.1590/S0104-44782010000200017 Lamonato LCXL, Sarti TD, Almeida APSC. Efeito da Atenção Primária à Saúde na associação entre multimorbidade e utilização dos serviços de emergência: Pesquisa Nacional de Saúde (PNS), 2019. Rev Bras Epidemiol . 2024;27:e240062. [cited 2025 May 10]. Available from: https://doi.org/10.1590/1980-549720240062.2 Delpino FM, Vieira YP, Duro SM, Nunes BP, Saes MDO. Multimorbidade e uso de serviços de saúde em população diagnosticada com covid-19 em município da região Sul do Brasil, 2020–2021: estudo transversal. Epidemiol Serv Saude . 2024;33:e2023915. [cited 2025 May 22]. Available from: https://doi.org/10.1590/S2237-96222024V33E2023915.EN Chiu YM, Vanasse A, Courteau J, Chouinard MC, Dubois MF, Dubuc N et al. Persistent frequent emergency department users with chronic conditions: a population-based cohort study. PLoS One . 2020;15(2):e0229022. [cited 2025 Jan 13]. Available from: https://doi.org/10.1371/journal.pone.0229022 Memedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E et al. A mapping review of interventions to address patients who frequently seek care in the emergency department. BMC Emerg Med . 2024;24(1):49. [cited 2025 May 30]. Available from: https://doi.org/10.1186/s12873-024-00970-7 O’Cathain A, Connell J, Long J, Coster J. ‘Clinically unnecessary’ use of emergency and urgent care: a realist review of patients’ decision making. Health Expect . 2020;23(1):19–40. [cited 2025 Jan 06]. Available from: https://doi.org/10.1111/hex.12995 Carret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res . 2007;7(1):131. [cited 2024 Aug 11]. Available from: https://doi.org/10.1186/1472-6963-7-131 de Souza Amarante LC, Gonçalo Mialhe C, Guerra LM, Vilela Bugarelli de Faria J, Mialhe FL. Motivos apresentados por usuários para a utilização inadequada de Unidades de Pronto Atendimento. Rev Salud Pública . 2023;22:440–6. [cited 2025 Mar 22]. Available from: https://doi.org/10.15446/rsap.V22n4.54092 O’Keeffe C, Mason S, Jacques R, Nicholl J. Characterising non-urgent users of the emergency department (ED): a retrospective analysis of routine ED data. PLoS One . 2018;13(2):e0192855. [cited 2024 Dec 10]. Available from: https://doi.org/10.1371/journal.pone.0192855 Yoon J, Cordasco KM, Chow A, Rubenstein LV. The relationship between same-day access and continuity in primary care and emergency department visits. PLoS One . 2015;10(9):e0135274. [cited 2024 Nov 15]. Available from: https://doi.org/10.1371/journal.pone.0135274 Cowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A et al. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. PLoS One . 2013;8(6):e66699. [cited 2024 Oct 06]. Available from: https://doi.org/10.1371/journal.pone.0066699 Murray M, Tantau C. Must patients wait? Jt Comm J Qual Improv . 1998;24(8):423–5. [cited 2025 Aug 19]. Available from: https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0--S1070324116303923/first-page-pdf Murray M, Tantau C. Same-day appointments: exploding the access paradigm. Fam Pract Manag . 2000;7(8):45–50. [cited 2025 Aug 19]. Available from: https://www.aafp.org/pubs/fpm/issues/2000/0900/p45.html de Gusmão Bonilla PP, Wollmann L. Avaliação da implantação do acesso avançado nos indicadores de qualidade de uma unidade de saúde. Rev Bras Med Fam Comunidade . 2020;15(42):2360. [cited 2025 Aug 19] Available from: https://doi.org/10.5712/rbmfc15(42)2360 Pinto AR, Oliveira LGF, Fracolli LA, Nichiata LYI. Bases de implantação e pilares de sustentação do Acesso Avançado: convite ao debate. Saúde Debate . 2025;49:e10134. [cited 2025 Aug 19]. Available from: https://doi.org/10.1590/2358-2898202514610134P Kraaijvanger N, Van Leeuwen H, Rijpsma D, Edwards M. Motives for self-referral to the emergency department: a systematic review of the literature. BMC Health Serv Res . 2016;16(1):685. [cited 2024 Nov 30]. Available from: https://doi.org/10.1186/s12913-016-1935-z Van den Berg MJ, Van Loenen T, Westert GP. Accessible and continuous primary care may help reduce rates of emergency department use. An international survey in 34 countries. Fam Pract . 2016;33(1):42–50. [cited 2024 Dec 02]. Available from: https://doi.org/10.1093/fampra/cmv082 Turrini RNT, Lebrão ML, Cesar CLG. Resolutividade dos serviços de saúde por inquérito domiciliar: percepção do usuário. Cad Saúde Pública . 2008;24:663–74. [cited 2024 Sep 10]. Available from: https://doi.org/10.1590/S0102-311X2008000300020 Additional Declarations No competing interests reported. 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16:34:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1467386,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7999517/v1/dc3d89e9-37ae-4546-a92e-2f053abc868c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Profile of Emergency Service Use in a Brazilian Capital City","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Brazilian health system consists of a complex network of services, historically built on social movements that sought to ensure universal and comprehensive access to health care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In this context, urgent and emergency care services play a strategic role as one of the main entry points to the Health System, focused on treating acute and highly serious conditions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConceptually, Ordinance n. 354 of 2014 establishes distinctions between the terms urgency and emergency. Emergency refers to the medical observation of worsening health conditions involving intense suffering or imminent risk of death. Urgency, on the other hand, refers to an unforeseen occurrence of health impairment, with or without potential risk to life. Both require immediate assistance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Brazil, the \"Unidades de Pronto Atendimento (UPAs)\" or \u0026ldquo;Pronto Atendimento (PA)\u0026rdquo; are emergency care units that are part of this network as intermediate-complexity facilities, operating between primary care and hospitals. Their functions include patient stabilization, the provision of pre-hospital care, the transfer of patients to other medical centers when necessary, as well as providing assistance in low-complexity acute cases when primary care services are not available[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, the use of these services by patients with minor complaints has become frequent, often due to barriers in accessing other levels of care, especially primary care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The literature also points to the belief in the greater effectiveness of the ED, the possibility of tests, immediate medication, and convenience as the main factors for seeking these services [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, this pattern of use can overload the units, compromise the effectiveness of care, and potentially be detrimental to continuity of care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven this, it is essential to understand the profile of users and the factors that influence the choice of these services in order to support strategies for organizing the network and improving access. This study aims to analyze the profile of users of an emergency department in the city of Vit\u0026oacute;ria (ES), as well as to identify the reasons that motivate the search for this service.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a cross-sectional study conducted in Vit\u0026oacute;ria, capital of the state of Esp\u0026iacute;rito Santo, Brazil, with the objective of analyzing the profile of users and factors associated with the use of an ED. Data collection was carried out over 30 consecutive days in November and December 2019, with 24-hour coverage.\u003c/p\u003e\u003cp\u003eThe municipality of Vit\u0026oacute;ria is the capital of the state of Esp\u0026iacute;rito Santo, located in the southeastern region of Brazil, with a population of 322,869 inhabitants [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In 2010, it recorded a Human Development Index (HDI) of 0.845, one of the highest in the country. The municipal health system is computerized, provides extensive coverage under the \"Estrat\u0026eacute;gia de Sa\u0026uacute;de da Fam\u0026iacute;lia (ESF)\" - the country\u0026rsquo;s primary care model - [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and offers a range of outpatient services. The city has two \u003cem\u003ePAs\u003c/em\u003e and an emergency network that operates continuously, 24 hours a day, seven days a week. The study was conducted in only one of these. Care follows the Manchester Protocol for risk classification [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and covers clinical care for adults and children, low complexity emergency care, minor surgical procedures, and emergency dental services. Because it is located in a metropolitan area, Vit\u0026oacute;ria receives an intense flow of people from neighboring municipalities, especially during business hours.\u003c/p\u003e\u003cp\u003eThe sample size was calculated based on an estimated prevalence of 24.2%, as obtained in Carret et al. (2009), in a study that used the same protocol to measure the inappropriate use of emergency services. A margin of error of \u0026plusmn;\u0026thinsp;2.5 percentage points and a confidence level of 95% were considered. Incorporating 10% for possible losses and/or refusals, the required sample size was estimated at 1,219 individuals. At the end of the collection, the sample reached 1,177 individuals.\u003c/p\u003e\u003cp\u003eIndividuals aged 18 years or older who were admitted to the ED and underwent the risk classification process were recruited. Individuals escorted by police officers, as well as those who sought the service to obtain medication or for administrative reasons, were excluded from the study.\u003c/p\u003e\u003cp\u003eParticipants were selected by systematic random sampling. Inside the clinical risk stratification room, the first participant was chosen at random, and after this initial selection, one in every 11 individuals was included, ensuring a systematic and consistent process.\u003c/p\u003e\u003cp\u003eThe interviews were conducted in the emergency room using a structured questionnaire that addressed sociodemographic information, the reason for the visit to the ED, medical history, self-perceived health, and comorbidities. The interviews were conducted by a trained team, all over the age of 18 and under supervision.\u003c/p\u003e\u003cp\u003eThe variables analyzed included sex (female/male), skin color (white/black/Mixed-Race/indigenous-asian), years (18\u0026ndash;39 years/39\u0026ndash;59 years/60 years or older), marital status (married/single/separated/widowed), Level of education (None and Incomplete Fundamental school/Fundamental school/Middle school /Graduation and Postgraduate Studies), economic status by Brazilian Economic Classification Criteria (Brazilian Criteria) \u0026ndash; ABEP, Possession of private health insurance or a discount card (No / Discount card / Private health insurance), self-assessment of health (very poor-poor/Fair/Good-Excellent), multimorbidity (Yes/No), sought care elsewhere (No/Yes), Where did you seek care first (PHC unit/Emergency care unit/Private hospital emergency room/Private practice ), Did you get care on your first try? (No/Yes), Why weren't you seen on this first attempt?\u003cb\u003e(\u003c/b\u003eCould not get an appointment/No doctor available/No professional available/Waited and gave up/It wasn\u0026rsquo;t working/Couldn\u0026rsquo;t afford it), self-perceived need (Yes/No), has a reference primary health clinic (Yes/No), presence of a reference physician or nurse (Yes/No), Why didn't you see a doctor/nurse today ( The place where he or she works was closed/My case is ED/ He couldn't see me/He referred me to the ED/Other), day of visit (Monday to Friday/ Saturday and Sunday ), time of visit (6 p.m.-6 a.m./7 a.m.-5 p.m.), How did you get to this ED? (Walking-Bus/Car-Taxi/Ambulance/Other), use of the ED in the last year(None/1\u0026ndash;2 times/3\u0026ndash;4 times/5 or more times), Inappropriate use of Emergency Care Unit (Yes/No), risk stratification - Manchester Protocol ( green and blue/yellow/ orange and red), self-perceived urgency (Yes/No) and If it's not serious, why did you come to the ED? (The ED is better equipped to handle it/ Possibility of undergoing tests at the time of consultation/Possibility of receiving medication / Unable to make an appointment at the Health Unit/Health unit only operates during working hours) - this variable was treated as a multiple-response variable, as participants could select more than one reason.\u003c/p\u003e\u003cp\u003eThe assessment of the self-perceived urgency of the health condition by the individual was carried out by asking the question: \u0026ldquo;Do you consider your problem to be very serious and requiring immediate attention?\u0026rdquo;. The self-perceived need to go to the emergency room was investigated with the following question: \u0026ldquo;If it were possible to easily obtain care from a competent health professional at the primary care center closest to your home or work (where you are registered/referred), would you have come here?\u0026rdquo;\u003c/p\u003e\u003cp\u003eMultimorbidity, defined as the simultaneous presence of two or more chronic diseases, was determined based on the coexistence of the following self-reported health conditions: asthma, osteoporosis, arthritis, hypertension, diabetes, heart disease, pulmonary emphysema, or COPD, Parkinson's disease, renal failure, prostate diseases, thyroid disorders, glaucoma, cataracts, Alzheimer's disease, urinary or fecal incontinence, angina, stroke, high cholesterol, epilepsy, depression, urinary tract infection, and cancer.\u003c/p\u003e\u003cp\u003eInappropriate use was assessed using the Hospital Urgency Appropriateness Protocol (HUAP) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], a validated instrument in Brazil [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] to identify misuse of emergency services, based on five criteria: severity, treatment requirements, diagnostic intensity, need for observation and/or prolonged transfer, and self-referral. Inappropriate use was defined as not meeting any of the 28 criteria evaluated by the HUAP. The research team, with access to the patient's medical records and support from the doctor on duty, completed the criteria after the consultation.\u003c/p\u003e\u003cp\u003ePrevalence rates were estimated with 95% confidence intervals (95% CI). Data analysis was performed using StataSE version 17.0 software.\u003c/p\u003e\u003cp\u003eIn order to facilitate interpretation, we chose to present the data referring to both the total sample of users and the residents of Vit\u0026oacute;ria in a table. However, the discussion will focus on the data from the general sample.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003e[Insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cb\u003ehere.]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSample description of the use of the Emergency Care Unit. Vit\u0026oacute;ria, Brazil, 2019.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eVit\u0026oacute;ria* (n\u0026thinsp;=\u0026thinsp;915)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTotal** (n\u0026thinsp;=\u0026thinsp;1,177)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables (n*= 912; n**= 1.174)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e565\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.0 (58.7\u0026ndash;65.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e732\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.4 (59.5\u0026ndash;65.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e347\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.1 (34.9\u0026ndash;42.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e442\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.6 (34.9\u0026ndash;40.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSkin color (n*=911; n**=1.168)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.7 (19.2\u0026ndash;24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e256\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.9 (19.6\u0026ndash;24.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.8 (19.3\u0026ndash;24.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.9 (18.7\u0026ndash;23.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMixed-Race\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e495\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.3 (51.1\u0026ndash;57.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e642\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e55.0 (52.1\u0026ndash;57.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndigenous/Asian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.1 (1.3\u0026ndash;3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.2 (1.5\u0026ndash;3.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eYears (n*=911; n**= 1.173)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;39 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e530\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.2 (54.9\u0026ndash;61.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e678\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e57.8 (54.9\u0026ndash;60.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;59 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e252\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.7 (24.8\u0026ndash;30.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.4 (25.9\u0026ndash;31.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60 or older years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.2 (12.0-16.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.8 (12.0\u0026ndash;15.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status (n*= 912 n**= 1.173)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e433\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.5 (44.2\u0026ndash;50.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e565\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48.2 (45.3\u0026ndash;51.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e340\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.3 (34.2\u0026ndash;40.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e439\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.4 (34.7\u0026ndash;40.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeparated/divorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.6 (8.8\u0026ndash;12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e119\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.1 (8.5\u0026ndash;12.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.6 (3.4\u0026ndash;6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.3 (3.2\u0026ndash;5.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of education (n*=915; n**=1.177)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone and Incomplete Fundamental school (0 to 7 years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.9 (14.6\u0026ndash;19.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e202\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.2 (15.1\u0026ndash;19.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFundamental school (8 to 10 years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.1 (17.6\u0026ndash;22.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.9 (16.7\u0026ndash;21.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle school (11 to 14 years old)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e396\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.3 (40.1\u0026ndash;46.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e526\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.7 (41.9\u0026ndash;47.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGraduation and Postgraduate Studies (15 years or older)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.7 (17.2\u0026ndash;22.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e227\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.3 (17.1\u0026ndash;21.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEconomic Status (ABEP) (n*=910; n**= 1.165)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA - B\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e261\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.7 (25.8\u0026ndash;31.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e338\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29 (26.5\u0026ndash;31.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e535\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.8 (55.6\u0026ndash;62.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e680\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.4 (55.5\u0026ndash;61.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD - E\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.5 (10.5\u0026ndash;14.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.6 (10.8\u0026ndash;14.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePossession of private health insurance or a discount card (n*= 907; n**= 1,166)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e799\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.1 (85.8\u0026ndash;90.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.4 (85.1\u0026ndash;89.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiscount card\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2 (3.1\u0026ndash;5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.4 (3.3\u0026ndash;5.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate Health insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.7 (6.1\u0026ndash;9.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.2 (6,7- 9,9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-assessment of health (n*=910; n**= 1.172)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVery poor - Poor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.0 (16.6\u0026ndash;21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e237\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.2 (18.0\u0026ndash;22.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.5 (31.5\u0026ndash;37.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e413\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.2 (32.6\u0026ndash;38.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood - Excellent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e423\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.5 (43.3\u0026ndash;49.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.5 (41.7\u0026ndash;47.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMultimorbidity (n*=902; n**= 1.162)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e411\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.6 (42.3\u0026ndash;48.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e529\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.5 (42.7\u0026ndash;48.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e491\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.4 (51.2\u0026ndash;57.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e633\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.5 (51.6\u0026ndash;57.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e*:Sample of residents of Vit\u0026oacute;ria; **:Total study sample; CI: Confidence interval 95%; ABEP: Brazilian Economic Classification Criteria\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOf the 1,232 eligible individuals invited, 1,177 (94.5%) agreed to participate in the study. The sample consisted mainly of females (62.4%; 95% CI 59.5\u0026ndash;65.1), young adults ( 57.8%; 95% CI 54.9\u0026ndash;60.6), self-declared Mixed-Race (55%; 95% CI 52.1\u0026ndash;57.8), married (48.2; 95% CI 45.3\u0026ndash;51.0), with average schooling (44.7%; 95% CI 41.9\u0026ndash;47.5), belonging to economic class C (58.4; 95% CI 55.5\u0026ndash;61.2), without private health insurance (86.7%; 95% CI 84.7\u0026ndash;88.6), who assess their health status as satisfactory (44.5; 95% CI 41.7\u0026ndash;47.4). A significant number of people have multimorbidity (45.5%; 95% CI 42.7\u0026ndash;48.4) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). It was observed that 77.7% (915) of respondents were residents of Vit\u0026oacute;ria, while 22.3% (262) resided in other municipalities but sought care at the municipality's emergency department. The sociodemographic profile of non-residents was similar to that of residents, with a predominance of females, young adults, self-declared black or mixed-race, belonging to economic class C, without health insurance, and with a positive assessment of their health status.\u003c/p\u003e\u003cp\u003e\u003cb\u003e[Insert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cb\u003ehere.]\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of access to emergency care in the sample. Vit\u0026oacute;ria, Brazil, 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eVit\u0026oacute;ria *\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTotal **\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSought care elsewhere (n*= 913; n**= 1.173)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e253\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.7 (24.9\u0026ndash;30.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.3 (25.8\u0026ndash;30.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e660\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.3 (69.3\u0026ndash;75.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e841\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71.7 (69.0\u0026ndash;74.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhere did you seek care first? (n*=250 ; n**=328 )\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePHC unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.6 (56.4\u0026ndash;68.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53.2 (47.8\u0026ndash;58.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmergency care unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.8 (16.2\u0026ndash;26.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.5 (22.0\u0026ndash;31.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate hospital emergency room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0 (2.2\u0026ndash;7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.0 (2.3\u0026ndash;6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.6 (1.9\u0026ndash;6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.0 (2.3\u0026ndash;6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther services\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.0 (5.2\u0026ndash;12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.5 (6.0 - 12.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDid you get care on your first try? (n*=249; n**=327)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e167\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.1 (61.0\u0026ndash;72.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e221\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67.6 (62.3\u0026ndash;72.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.9 (27.4\u0026ndash;39.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32.4 (27.5\u0026ndash;37.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhy weren't you seen on this first attempt? (n*=80; n**=103 )\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCould not get an appointment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.3 (26.4\u0026ndash;47.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.1 (22.8\u0026ndash;40.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo doctor available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.3 (5.9\u0026ndash;20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.6 (7.4\u0026ndash;20.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo professional available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.3 (5.9\u0026ndash;20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.6 (7.4\u0026ndash;20.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWaited and gave up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.8 (11.5\u0026ndash;29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.5 (12.0\u0026ndash;27.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIt wasn\u0026rsquo;t working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.0 (1.9\u0026ndash;12.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.9 (1.4\u0026ndash;10.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCouldn\u0026rsquo;t afford it\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.3 (0.17\u0026ndash;8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0 (0.1\u0026ndash;6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.3 (9.6\u0026ndash;26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.4 (13.6\u0026ndash;29.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eself-perceived need\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.8 (23.1\u0026ndash;28.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.8 (24.4\u0026ndash;29.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e675\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.2 (71.2\u0026ndash;76.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e854\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.2 (70.6\u0026ndash;75.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReference PHC clinic (n*= 914; n**=1.176)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.6 (74.7\u0026ndash;80.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e849\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e72.2 (69.6\u0026ndash;74.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.4 (19.8\u0026ndash;25.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e327\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27.8 (25.3\u0026ndash;30.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFamily physician and nurse reference (n*= 914; n**=1.176)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.3 (27.4\u0026ndash;33.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e321\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27.3 (24.8\u0026ndash;29.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.7 (66.6\u0026ndash;72.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e855\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e72.7 (70.1\u0026ndash;75.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWhy didn't you see a\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003edoctor/nurse today? (n*=271; n**= 310)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe place where he/she works was closed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.1 (20.3\u0026ndash;30.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.7 (19.3\u0026ndash;28.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMy case is ED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.6 (14.4\u0026ndash;23.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.4 (14.4\u0026ndash;23.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHe couldn't see me\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.7 (9.3\u0026ndash;17.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.0 (9.7\u0026ndash;17.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHe referred me to the ED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.0 (5.3\u0026ndash;11.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.9 (5.4\u0026ndash;11.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.2 (28.8\u0026ndash;40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.1 (30.0\u0026ndash;40.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDay of visit (n*= 910; n**=1.170)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMo - Fr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.3 (72.4\u0026ndash;78.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75.0 (72.4\u0026ndash;77.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSat - Sun\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e225\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.7 (22.0\u0026ndash;27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e293\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25.0 (22.6\u0026ndash;27.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTime of visit (n*=912; n**= 1.169)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6 p.m - 6 a.m.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.0 (32.9\u0026ndash;39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.6 (32.9\u0026ndash;38.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7 a.m \u0026minus;\u0026thinsp;5 p.m.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e584\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.0 (60.9\u0026ndash;67.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e753\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.4 (61.6\u0026ndash;67.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHow did you get to this ED? (n*= 912; n**= 1.174)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWalking/bus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e367\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.2 (37.1\u0026ndash;43.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e468\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.9 (37.1\u0026ndash;42.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaxi/Car\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e484\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.1 (49.8\u0026ndash;56.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e630\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53.7 (50.8\u0026ndash;56.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmbulance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0 (0.5\u0026ndash;1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.3 (0.8\u0026ndash;2.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.7 (4.4\u0026ndash;7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.2 (4.1\u0026ndash;6.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUse of the ED in the last year (n*= 894; n**=1.155)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.6 (16.2\u0026ndash;21.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.7 (15.6\u0026ndash;20.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.1 (32.1\u0026ndash;38.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e418\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36.2 (33.5\u0026ndash;39.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.2 (20.5\u0026ndash;26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.9 (20.6\u0026ndash;25.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5 or more times\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.2 (20.5\u0026ndash;26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.1 (20.8\u0026ndash;25.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInappropriate use of Emergency Care Unit (n*= 858; n**=1.098)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.0 (27.0\u0026ndash;33.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.3 (26.7\u0026ndash;32.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e601\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.1 (66.9\u0026ndash;73.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e776\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e70.7 (67.9\u0026ndash;73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e*:Sample of residents of Vit\u0026oacute;ria; **:Total study sample; CI: Confidence interval 95%; PHC: Primary health care; ED: Emergence department.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMost respondents sought care directly at the emergency department (71.7%; 95% CI: 69.0\u0026ndash;74.2). However, in their self-assessment of need, only 26.8% (95% CI: 24.4\u0026ndash;29.4) considered emergency care to be truly necessary. Among those who sought care before going to the ED, 67.6% (95% CI: 62.3\u0026ndash;72.5) received care, and the main place they sought care was the PHC unit (53.2%; 95% CI: 47.8\u0026ndash;58.6). On the other hand, among those who were not treated on this first attempt (32.4%; 95% CI: 27.5\u0026ndash;37.7), the main reason reported was the lack of vacancies (31.1%; 95% CI: 22.8\u0026ndash;40.7) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, 72.7% (95% CI: 70.1\u0026ndash;75.2) of ED users reported not having a primary care physician or nurse, however, 72.2% (95% CI: 69.6\u0026ndash;74.7) reported having a primary care unit. Among those who stated that they had a referral professional, the main reason for not seeking them was that the facility was closed at the time of the search (23.7%; 95% CI: 19.3\u0026ndash; 28.8) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).Care was mainly provided on weekdays (75.0%; 95% CI: 72.4\u0026ndash;77.4) and during PHC opening hours (64.4%; 95% CI: 61.6\u0026ndash;67.1). The main means of transportation to the ED was taxi or private car (53.7%; 95% CI: 50.8\u0026ndash;56.5). Most had used the ED one or more times in the past 12 months (82.3%; 95% CI: 79.9\u0026ndash;84.4), and a significant proportion made inappropriate use of the service (29.3%; 95% CI: 26.7\u0026ndash;32.1) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eUrgency of Care. Vit\u0026oacute;ria, Brazil, 2019\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eVit\u0026oacute;ria\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eriskstratification-Manchester Protocol (n*=914; n**=1.175)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGreen and blue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e668\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.1 (70.1\u0026ndash;75.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e858\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73.0 (70.4\u0026ndash;75.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYellow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.76 (20.2\u0026ndash;25.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.9 (20.6\u0026ndash;25.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRed and Orange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2 (3.03\u0026ndash;5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.1 (3.1\u0026ndash;5.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSelf-perceived urgency (n*=912; n**=1.171)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e683\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.9 (72.0\u0026ndash;77.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e892\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76.2 (73.6\u0026ndash;78.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.1 (22.4\u0026ndash;28.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e279\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.8 (21.5\u0026ndash;26.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIf it's not serious, why did you come to the ED? (n*= 216; n**= 265)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe ED is better equipped to handle it\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.9 (21.3\u0026ndash;33.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.7 (23.5\u0026ndash;34.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePossibility of undergoing tests at the time of consultation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.0 (10.8\u0026ndash;20.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.5 (10.7\u0026ndash;19.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePossibility of receiving medication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.4 (12.0\u0026ndash;22.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.8 (12.7\u0026ndash;21.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnable to make an appointment at the Health Unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.6 (9.6\u0026ndash;18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.2 ( 8.8\u0026ndash;16.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth unit only operates during working hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.7 (8.0\u0026ndash;16.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.1 (7.8\u0026ndash;15.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.1 (58,5\u0026ndash;71,2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.8 (58.8\u0026ndash;70.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e*:Sample of residents of Vit\u0026oacute;ria; **:Total study sample; CI: Confidence interval 95%; \u0026lsquo;If it's not serious, why did you come to the ED?\u0026rsquo; is a multiple-response variable.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding severity, most users perceived their condition as urgent (76.2%; 95% CI: 73.6\u0026ndash; 78.5), despite most of them being classified as non-urgent or slightly urgent cases (73.0%; 95% CI: 70.4\u0026ndash;75.5). Among those who did not consider the problem serious (23.8%; 95% CI: 21.5\u0026ndash;26.4), the most frequently cited reason for seeking emergency care was the belief that the service is more effective (28.7%; 95% CI: 23.5\u0026ndash;34.0) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe data from 1,177 participants allowed us to characterize the profile of ED users and identify the reasons for seeking this level of care. The sample consisted mainly of young adults, female, self-declared Mixed-Race, socioeconomic class C, with complete high school education, without health insurance, who rated their health status as good or excellent. Almost half had multimorbidity, most sought ED care directly, and were classified as non-urgent. Approximately one-third made inappropriate use of the service, according to the HUAP protocol.\u003c/p\u003e\u003cp\u003eThe predominance of women and young people in the use of emergency services was observed in different Brazilian national studies, both with similar methodologies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and with secondary data [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The higher proportion of users classified as low risk by service protocols was also consistent [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The absence of private health insurance and positive self-assessment of health status were consistent with the findings of studies conducted in Piracicaba (SP) and Pelotas (RS), Brazil [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the results regarding education and skin color differed. In this study, most users had between 11 and 14 years of schooling and self-identified as mixed-race, while other studies pointed to a predominance of elementary school education and white people [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe reality of Vit\u0026oacute;ria, which has one of the highest Human Development Index (HDI) ratings in the country [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], may contribute to the higher educational level observed in the sample analyzed. With regard to the color/race variable, it is necessary to consider that the southern region of Brazil, where one of the studies with divergent results was conducted, has the highest proportion of self-declared white people in Brazil [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. At the same time, recent studies point to a significant increase in the self-declaration of black and mixed-race people at the national level [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which may reflect changes in racial self-perception and influence the results found in this study. It should also be noted that the race/color variable is complex, influenced by sociocultural and historical factors and by the subjective experiences of individuals [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, it is observed that, although the sample has a higher proportion of individuals with complete high school education and self-declared mixed-race, when compared to the demographic profile of the general population of Vit\u0026oacute;ria [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the ED was proportionally more used by people with elementary school education, in line with findings from studies conducted in other locations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and by self-declared black individuals, which reinforces the divergence observed regarding the race/color variable.\u003c/p\u003e\u003cp\u003eRegarding clinical conditions, almost half of the users had multimorbidity (two or more chronic diseases), a proportion about 1.5 times higher than the national average [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Individuals with multiple chronic diseases tend to use emergency services at least twice as often as those without such conditions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In addition, more than 80% of respondents had used the emergency department in the last year, with almost half considered frequent users, a criterion associated with financial and operational overload for services [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother relevant finding was the discrepancy between users' perceptions and risk classification: more than 76% believed that the problem was serious, although 73% were assessed as low-risk cases by the Manchester protocol. The literature points out that self perception of severity is a determining factor in the choice of service [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and anxiety in the face of uncertainty about symptoms, as well as previous negative experiences, contribute to the overestimation of this severity [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, although most cases were classified as low risk, a considerably smaller proportion was identified as inappropriate use according to the HUAP protocol, showing that low risk classification does not necessarily equate to inappropriate use of this equipment. Furthermore, the prevalence is similar to that recorded in Pelotas (RS), with 24.2% [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], but almost half that identified in Ouro Preto (MG) by the same protocol [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], indicating that organizational and cultural factors may influence estimates of inappropriate use of emergency services.\u003c/p\u003e\u003cp\u003eThe findings also suggest weaknesses in primary care. Although most respondents have a PHC unit in their territory, more than 70% stated that they do not have a referral doctor or nurse. Among those who did have one, the main reason for not seeking this professional was that the service location was closed, which could possibly be resolved by extending the opening hours of PHC [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, it is important to note that most visits to the emergency department occurred on weekdays and during PHC opening hours, which indicates that, although opening hours may be a relevant factor, they are not the only or main determinant in the choice.\u003c/p\u003e\u003cp\u003eThe perception of greater effectiveness in emergency services, identified in this study, coupled with the belief that PHC lacks the resources to adequately address certain health problems, seems to be a strong influence on the choice of the ED by users in non-urgent situations, as also demonstrated in qualitative research with this same population [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Evidence suggests that timely access to PHC, especially when same-day care is available [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] or within two business days [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], is associated with a reduction in emergency room visits for non-emergency demands [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this context, initiatives such as Advanced Access (AA) have been studied as alternatives to balance supply and demand in PHC. The model, initially proposed in the United States in the 1990s and progressively adopted in countries such as England, Canada, Brazil, and Australia, proposes care within 48 hours of the request, regardless of the nature of the problem [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Brazilian experiences have shown improvement in access and performance indicators after its implementation, in addition to a reduction of almost 10% in secondary referral care [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. However, there is still little evidence of its impact on the use of emergency care units in the country, and the modality is not characterized as emergency care, as it requires prior scheduling [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe pattern of direct demand for emergency care has been identified in other Brazilian municipalities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. On the other hand, about 15% of our interviewees reported having\u003c/p\u003e\u003cp\u003esought care at the PHC before going to the ED, a result similar to that found in a review that pointed out that 13% of self-reported individuals resorted to the emergency room due to difficulty in accessing primary care [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In several countries, it has been found that low accessibility to PHC increases the demand for emergency services, while the link with a referral physician reduces this demand [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In Brazil, an association has been found between the coverage of the \u003cem\u003eESF\u003c/em\u003e and a reduction in the use of emergency services. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe local context also needs to be considered. Vit\u0026oacute;ria receives an intense flow of workers from neighboring municipalities, especially in the region where the ED is located, close to commercial areas. The geographical proximity of home or workplace influences the choice of health service [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Thus, the difficulty of PHC units in meeting demands outside their coverage area may contribute to the demand for emergency services, even in cases of low severity.\u003c/p\u003e\u003cp\u003eIn summary, the results reinforce that the search for emergency care stems from multiple factors: sociodemographic characteristics, multimorbidity, perception of severity, lack of connection with PHC professionals, and organizational issues. The expectation that users will make conscious and appropriate choices between different levels of health care is unrealistic, since sometimes the service considered ideal from a technical point of view does not correspond to the expectations, perceived needs, or reality experienced by these individuals. Evidence suggests that building a comprehensive, accessible PHC that provides timely care is more likely to attract users and establish itself as the preferred point of entry, potentially alleviating the burden on emergency services.\u003c/p\u003e\u003cp\u003eDespite the valuable insights provided by this cross-sectional study, it also has inherent limitations. The absence of an established causal relationship and the presence of temporal ambiguity limit the possibility of drawing definitive conclusions about the relationships between variables. The results may also have been influenced by biases, as the interviews were conducted in the waiting room of the Emergency Care Unit, which may have affected participants' responses due to the context of waiting for care. Furthermore, the study sample may not correspond to all users of emergency care services, since companions and/or patients in serious condition may not have been able to participate in the interviews, which excludes an important part of the population served in the emergency room. Considering the socioeconomic, environmental, and healthcare structure differences between communities, the generalization of the information in this study to other Brazilian regions or other countries should be done with caution.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings reveal that among ED users, the service is often used as the first option for accessing the Health System, with most choosing to seek care directly at the facility, even when PHC are in operation. Among those who sought prior care, more than 50% reported unsatisfactory experiences with the PHC, indicating that the failures in primary care are not only due to limited opening hours during the week, but mainly to the unavailability of the services offered. Thus, although the expansion of the number of establishments is relevant,\u003c/p\u003e\u003cp\u003eit is equally crucial to reassess the logic of care so that it aligns with the needs of the population, ensuring compliance with the principles and guidelines of the \u0026ldquo;\u003cem\u003eSistema Unico de Sa\u0026uacute;de (SUS)\u003c/em\u003e\u0026rdquo;- The Brazilian healthcare system.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eED\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHUAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHospital Urgency Appropriateness Protocol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Health Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eUPA\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eUnidade de Pronto Atendimento\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003ePA\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003ePronto Atendimento\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eES\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eEsp\u0026iacute;rito Santo\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHDI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Development Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIBGE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBrazilian Institute of Geography and Statistics\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eESF\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eEstrat\u0026eacute;gia de sa\u0026uacute;de da fam\u0026iacute;lia\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABEP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBrazilian Economic Classification Criteria (Brazilian Criteria)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Obstructive Pulmonary Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eSP\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eS\u0026atilde;o Paulo\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eRS\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eRio Grande do Sul\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eMG\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eMinas Gerais\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdvanced Access\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eSUS\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eSistema \u0026Uacute;nico de Sa\u0026uacute;de\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was approved by \u0026nbsp;the Medical School Ethics Committee of the Federal University of Esp\u0026iacute;rito Santo (Certificate of Presentation of Ethical Appreciation-CAAE: 13990719.4.0000.5060), and all participants signed the informed consent form. All procedures were conducted in accordance with the Declaration of Helsinki and Resolution No. 466/2012 of the Brazilian National Committee of Ethics in Research (CONEP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Conselho Nacional de Desenvolvimento Cient\u0026iacute;fico e Tecnol\u0026oacute;gico (CNPq) and the Funda\u0026ccedil;\u0026atilde;o de Amparo \u0026agrave; Pesquisa e Inova\u0026ccedil;\u0026atilde;o do Esp\u0026iacute;rito Santo (FAPES), through Call No. 07/2020 \u0026ndash; Capixaba Postgraduate Excellence Support Program (PROAPEX).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eE.J.F performed data analysis interpretation and drafted the manuscript. L.F.F contributed to data curation, to the drafting and reviewed the manuscript. \u0026nbsp; B. C. S.F.S ; \u0026nbsp;M.E.S.V; \u0026nbsp;R.B.E; T.D.A; A.P.S.C.A contributed to the drafting and reviewed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEJF, BCSFS, \u0026nbsp;MESV e \u0026nbsp; RBE are postgraduate students at the Federal University of Esp\u0026iacute;rito Santo, Vit\u0026oacute;ria, Brazil. LFF, TDS and APSCA are professors in the Department of Collective Health, Federal University of Esp\u0026iacute;rito Santo, Vit\u0026oacute;ria, Brazil.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFederal University of Esp\u0026iacute;rito Santo, Vit\u0026oacute;ria, Brazil\u003c/p\u003e\n\u003cp\u003eEmily de jesus Fraga, B\u0026aacute;rbara C\u0026aacute;ssia de Santana Farias Santos, Mariana Endlich Suave Vaz, Raissa Bamberg Elauar, Leonardo Ferreira Fontenelle, Thiago Dias Sarti e Ana Paula Santana Coelho Almeida\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePaim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011;377(9779):1778\u0026ndash;97. [cited 2024 Jul 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://repositorio.ufba.br/bitstream/ri/3028/1/Per%20int%202011.12.pdf\u003c/span\u003e\u003cspan address=\"https://repositorio.ufba.br/bitstream/ri/3028/1/Per%20int%202011.12.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSousa KHJF, Damasceno CKCS, Almeida CAPL, Magalh\u0026atilde;es JM, Ferreira MDA. Humaniza\u0026ccedil;\u0026atilde;o nos servi\u0026ccedil;os de urg\u0026ecirc;ncia e emerg\u0026ecirc;ncia: contribui\u0026ccedil;\u0026otilde;es para o cuidado de enfermagem. Rev Ga\u0026uacute;cha Enferm. 2019;40:e20180263. [cited 2024 Jul 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1983-1447.2019.20180263\u003c/span\u003e\u003cspan address=\"10.1590/1983-1447.2019.20180263\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrasil. Minist\u0026eacute;rio da Sa\u0026uacute;de. Portaria n\u0026ordm; 354, de 10 de mar\u0026ccedil;o de 2014., Define diretrizes para implanta\u0026ccedil;\u0026atilde;o do componente Unidade de Pronto Atendimento (UPA 24h) e do conjunto de servi\u0026ccedil;os de urg\u0026ecirc;ncia 24 horas da Rede de Aten\u0026ccedil;\u0026atilde;o \u0026agrave;s Urg\u0026ecirc;ncias. Di\u0026aacute;rio Oficial da Uni\u0026atilde;o. 2014 mar 11;48(Se\u0026ccedil;\u0026atilde;o 1):58\u0026ndash;9. [cited 2024 Jul 18]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/prt0354_10_03_2014.html\u003c/span\u003e\u003cspan address=\"https://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/prt0354_10_03_2014.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrasil. Minist\u0026eacute;rio da Sa\u0026uacute;de. Pol\u0026iacute;tica Nacional de Aten\u0026ccedil;\u0026atilde;o \u0026agrave;s Urg\u0026ecirc;ncias. 3\u0026ordf; ed. Bras\u0026iacute;lia: Minist\u0026eacute;rio da Sa\u0026uacute;de; 2013. [cited 2024 Jul 21]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_urgencias_3ed.pdf\u003c/span\u003e\u003cspan address=\"https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_urgencias_3ed.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDourado I, Medina MG, Aquino R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). Int J Equity Health. 2016;15(1):151. [cited 2024 Aug 01]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12939-016-0440-7\u003c/span\u003e\u003cspan address=\"10.1186/s12939-016-0440-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSouza LCD, Ambrosano GMB, Moraes KL, Fonseca EPD, Mialhe FL. Fatores associados ao uso n\u0026atilde;o urgente de unidades de pronto atendimento: uma abordagem multin\u0026iacute;vel. \u003cem\u003eCad Sa\u0026uacute;de Coletiva\u003c/em\u003e. 2020;28(1):56\u0026ndash;65. [cited 2024 Aug 05]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1414-462X202000280354\u003c/span\u003e\u003cspan address=\"10.1590/1414-462X202000280354\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. \u003cem\u003eAcad Emerg Med\u003c/em\u003e. 2017;24(9):1137\u0026ndash;49. [cited 2024 Aug 08]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/acem.13220\u003c/span\u003e\u003cspan address=\"10.1111/acem.13220\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnwin M, Kinsman L, Rigby S. Why are we waiting? Patients\u0026rsquo; perspectives for accessing emergency department services with non-urgent complaints. \u003cem\u003eInt Emerg Nurs\u003c/em\u003e. 2016;29:3\u0026ndash;8. [cited 2024 Aug 12]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ienj.2016.09.003\u003c/span\u003e\u003cspan address=\"10.1016/j.ienj.2016.09.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcIntyre A, Janzen S, Shepherd L, Kerr M, Booth R. An integrative review of adult patient-reported reasons for non-urgent use of the emergency department. \u003cem\u003eBMC Nurs\u003c/em\u003e. 2023;22(1):85. [cited 2025 Jan 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12912-023-01251-7\u003c/span\u003e\u003cspan address=\"10.1186/s12912-023-01251-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRodrigues MM, Sarti TD, Almeida APSC, Fontenelle LF, Lazarini WS. Uso de servi\u0026ccedil;o de emerg\u0026ecirc;ncia por motivos n\u0026atilde;o urgentes: estudo qualitativo com usu\u0026aacute;rios de um pronto atendimento, Vit\u0026oacute;ria ES, Brasil. 2019. \u003cem\u003eInterface Comun Sa\u0026uacute;de Educ\u003c/em\u003e. 2024;28:e230493. [cited 2025 Apr 02]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/interface.230493\u003c/span\u003e\u003cspan address=\"10.1590/interface.230493\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaratieri T, Lentsck MH, Corona LP, Almeida KPD, Kluthcovsky ACGC, Natal S. Fatores associados ao uso inapropriado do pronto atendimento. \u003cem\u003eCi\u0026ecirc;nc Sa\u0026uacute;de Coletiva\u003c/em\u003e. 2021;26(6):2281\u0026ndash;90. [cited 2024 Sep 02]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1413-81232021266.18532019\u003c/span\u003e\u003cspan address=\"10.1590/1413-81232021266.18532019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKanzaria HK, Niedzwiecki M, Cawley CL, Chapman C, Sabbagh SH, Riggs E et al. Frequent emergency department users: focusing solely on medical utilization misses the whole person. \u003cem\u003eHealth Aff (Millwood)\u003c/em\u003e. 2019;38(11):1866\u0026ndash;75. [cited 2024 Sep 10] Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1377/hlthaff.2019.00082\u003c/span\u003e\u003cspan address=\"10.1377/hlthaff.2019.00082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCenso. 2022 [Internet]. 2022. [cited 2025 Jan 06] Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://censo2022.ibge.gov.br/panorama/\u003c/span\u003e\u003cspan address=\"https://censo2022.ibge.gov.br/panorama/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarcelos MRB, Cohen SC, Brand\u0026atilde;o MRA, Cruz SCS, Zandonade E, Figueiredo TAM, Lima RDC. A trajet\u0026oacute;ria da Estrat\u0026eacute;gia de Sa\u0026uacute;de da Fam\u0026iacute;lia no munic\u0026iacute;pio de Vit\u0026oacute;ria, ES. \u003cem\u003eRev Bras Pesq Sa\u0026uacute;de\u003c/em\u003e. 2013;15(4). [cited 2025 Jun 14] Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://periodicos.ufes.br/rbps/article/view/7602\u003c/span\u003e\u003cspan address=\"https://periodicos.ufes.br/rbps/article/view/7602\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMendon\u0026ccedil;a MHM, Martins MIC, Giovanella L, Escorel S. Desafios para gest\u0026atilde;o do trabalho a partir de experi\u0026ecirc;ncias exitosas de expans\u0026atilde;o da Estrat\u0026eacute;gia de Sa\u0026uacute;de da Fam\u0026iacute;lia. \u003cem\u003eCi\u0026ecirc;nc Sa\u0026uacute;de Coletiva\u003c/em\u003e. 2010;15:2355\u0026ndash;65. [cited 2024 Sep 03]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scielosp.org/pdf/csc/2010.v15n5/2355-2365/pt\u003c/span\u003e\u003cspan address=\"https://www.scielosp.org/pdf/csc/2010.v15n5/2355-2365/pt\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRezende MRM, Ercole FF, Matos SS, Donoso MTV. Manchester Protocol at a school hospital emergency service. \u003cem\u003eRev Rene\u003c/em\u003e. 2016 Nov-Dec;17(6):843\u0026ndash;9. [cited 2025 Jun 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hdl.handle.net/1843/66482\u003c/span\u003e\u003cspan address=\"https://hdl.handle.net/1843/66482\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarret MLV, Fassa ACG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. \u003cem\u003eCad Saude Publica\u003c/em\u003e. 2009;25:7\u0026ndash;28. [cited 2024 Sep 20] Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S0102-311X2009000100002\u003c/span\u003e\u003cspan address=\"10.1590/S0102-311X2009000100002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSelva TS et al. Validez del protocolo de adecuaci\u0026oacute;n de urgencias hospitalarias. \u003cem\u003eRev Esp Salud Publica\u003c/em\u003e. 1999;73:461\u0026ndash;75. [cited 2025 Jun 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://scielo.isciii.es/scielo.php?script=sci_arttext\u0026amp;pid=S1135-57271999000400004\u0026amp;lng=e\u003c/span\u003e\u003cspan address=\"http://scielo.isciii.es/scielo.php?script=sci_arttext\u0026amp;pid=S1135-57271999000400004\u0026amp;lng=e\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOliveira RKCD, Santos AMRD, Nol\u0026ecirc;to JDS, S\u0026aacute; GGDM, Machado RDS, Gouveia MTDO, Madeira MZDA. Hospital emergency suitability protocol: translation and adaptation to the Brazilian culture. \u003cem\u003eRev Ga\u0026uacute;cha Enferm\u003c/em\u003e. 2022;43:e20210183. [cited 2025 Mar 06]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1983-1447.2022.20210183.en\u003c/span\u003e\u003cspan address=\"10.1590/1983-1447.2022.20210183.en\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMachado GVC, Oliveira FLPD, Barbosa HAL, Giatti L, Bonolo PDF. Fatores associados \u0026agrave; utiliza\u0026ccedil;\u0026atilde;o de um servi\u0026ccedil;o de urg\u0026ecirc;ncia/emerg\u0026ecirc;ncia, Preto O. 2012. \u003cem\u003eCad Sa\u0026uacute;de Coletiva\u003c/em\u003e. 2015;23(4):416\u0026ndash;24. [cited 2024 Nov 22]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1414-462X201500040177\u003c/span\u003e\u003cspan address=\"10.1590/1414-462X201500040177\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrito Santos P, Santos TPV, dos Santos PRA. Perfil dos usu\u0026aacute;rios e motivos de atendimentos em servi\u0026ccedil;os n\u0026atilde;o hospitalares fixos de urg\u0026ecirc;ncia e emerg\u0026ecirc;ncia. \u003cem\u003eRev Eletr Acervo Sa\u0026uacute;de\u003c/em\u003e. 2021;13(2):e6105. [cited 2025 Feb 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.25248/reas.e6105.2021\u003c/span\u003e\u003cspan address=\"10.25248/reas.e6105.2021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarcia VM, Reis RK. Perfil de usu\u0026aacute;rios atendidos em uma unidade n\u0026atilde;o hospitalar de urg\u0026ecirc;ncia. \u003cem\u003eRev Bras Enferm\u003c/em\u003e. 2014;67(2):261\u0026ndash;7. [cited 2024 Oct 25]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5935/0034-7167.20140035\u003c/span\u003e\u003cspan address=\"10.5935/0034-7167.20140035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVeloso IAM, Tib\u0026atilde;es HBB. Perfil de usu\u0026aacute;rios atendidos em um pronto atendimento de sa\u0026uacute;de. \u003cem\u003eRev Recien-Rev Cient Enferm\u003c/em\u003e. 2022;12(38):157\u0026ndash;64. [cited 2025 Feb 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.recien.com.br/index.php/Recien/article/view/644\u003c/span\u003e\u003cspan address=\"https://www.recien.com.br/index.php/Recien/article/view/644\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarret MLV, Fassa AG, Paniz VMV, Soares PC. Caracter\u0026iacute;sticas da demanda do servi\u0026ccedil;o de sa\u0026uacute;de de emerg\u0026ecirc;ncia no Sul do Brasil. \u003cem\u003eCi\u0026ecirc;nc Sa\u0026uacute;de Coletiva\u003c/em\u003e. 2011;16:1069\u0026ndash;79. [cited 2024 Sep 18]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S1413-81232011000700039\u003c/span\u003e\u003cspan address=\"10.1590/S1413-81232011000700039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIBGE. Censo 2022: pela primeira vez, desde 1991, a maior parte da popula\u0026ccedil;\u0026atilde;o do Brasil se declara parda. \u003cem\u003eAg\u0026ecirc;ncia de Not\u0026iacute;cias IBGE\u003c/em\u003e. 22 dez 2023. [cited 2025 Sep 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/38719-censo-2022-pela-primeira-vez-desde-1991-a-maior-parte-da-populacao-do-brasil-se-declara-parda\u003c/span\u003e\u003cspan address=\"https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/38719-censo-2022-pela-primeira-vez-desde-1991-a-maior-parte-da-populacao-do-brasil-se-declara-parda\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSzwarcwald CL, Stopa SR, Damacena GN, Almeida WDSD, Souza J\u0026uacute;nior PRBD, Vieira MLFP et al. Mudan\u0026ccedil;as no padr\u0026atilde;o de utiliza\u0026ccedil;\u0026atilde;o de servi\u0026ccedil;os de sa\u0026uacute;de no Brasil entre 2013 e 2019. \u003cem\u003eCi\u0026ecirc;nc Sa\u0026uacute;de Coletiva\u003c/em\u003e. 2021;26:2515\u0026ndash;28. [cited 2025 Feb 03]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1413-81232021266.1.43482020\u003c/span\u003e\u003cspan address=\"10.1590/1413-81232021266.1.43482020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuniz JO. Sobre o uso da vari\u0026aacute;vel ra\u0026ccedil;a-cor em estudos quantitativos. \u003cem\u003eRev Sociol Polit\u003c/em\u003e. 2010;18:277\u0026ndash;91. [cited 2024 Aug 27]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S0104-44782010000200017\u003c/span\u003e\u003cspan address=\"10.1590/S0104-44782010000200017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLamonato LCXL, Sarti TD, Almeida APSC. Efeito da Aten\u0026ccedil;\u0026atilde;o Prim\u0026aacute;ria \u0026agrave; Sa\u0026uacute;de na associa\u0026ccedil;\u0026atilde;o entre multimorbidade e utiliza\u0026ccedil;\u0026atilde;o dos servi\u0026ccedil;os de emerg\u0026ecirc;ncia: Pesquisa Nacional de Sa\u0026uacute;de (PNS), 2019. \u003cem\u003eRev Bras Epidemiol\u003c/em\u003e. 2024;27:e240062. [cited 2025 May 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1980-549720240062.2\u003c/span\u003e\u003cspan address=\"10.1590/1980-549720240062.2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDelpino FM, Vieira YP, Duro SM, Nunes BP, Saes MDO. Multimorbidade e uso de servi\u0026ccedil;os de sa\u0026uacute;de em popula\u0026ccedil;\u0026atilde;o diagnosticada com covid-19 em munic\u0026iacute;pio da regi\u0026atilde;o Sul do Brasil, 2020\u0026ndash;2021: estudo transversal. \u003cem\u003eEpidemiol Serv Saude\u003c/em\u003e. 2024;33:e2023915. [cited 2025 May 22]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S2237-96222024V33E2023915.EN\u003c/span\u003e\u003cspan address=\"10.1590/S2237-96222024V33E2023915.EN\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChiu YM, Vanasse A, Courteau J, Chouinard MC, Dubois MF, Dubuc N et al. Persistent frequent emergency department users with chronic conditions: a population-based cohort study. \u003cem\u003ePLoS One\u003c/em\u003e. 2020;15(2):e0229022. [cited 2025 Jan 13]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0229022\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0229022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMemedovich A, Asante B, Khan M, Eze N, Holroyd BR, Lang E et al. A mapping review of interventions to address patients who frequently seek care in the emergency department. \u003cem\u003eBMC Emerg Med\u003c/em\u003e. 2024;24(1):49. [cited 2025 May 30]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12873-024-00970-7\u003c/span\u003e\u003cspan address=\"10.1186/s12873-024-00970-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Cathain A, Connell J, Long J, Coster J. \u0026lsquo;Clinically unnecessary\u0026rsquo; use of emergency and urgent care: a realist review of patients\u0026rsquo; decision making. \u003cem\u003eHealth Expect\u003c/em\u003e. 2020;23(1):19\u0026ndash;40. [cited 2025 Jan 06]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/hex.12995\u003c/span\u003e\u003cspan address=\"10.1111/hex.12995\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2007;7(1):131. [cited 2024 Aug 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1472-6963-7-131\u003c/span\u003e\u003cspan address=\"10.1186/1472-6963-7-131\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Souza Amarante LC, Gon\u0026ccedil;alo Mialhe C, Guerra LM, Vilela Bugarelli de Faria J, Mialhe FL. Motivos apresentados por usu\u0026aacute;rios para a utiliza\u0026ccedil;\u0026atilde;o inadequada de Unidades de Pronto Atendimento. \u003cem\u003eRev Salud P\u0026uacute;blica\u003c/em\u003e. 2023;22:440\u0026ndash;6. [cited 2025 Mar 22]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15446/rsap.V22n4.54092\u003c/span\u003e\u003cspan address=\"10.15446/rsap.V22n4.54092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Keeffe C, Mason S, Jacques R, Nicholl J. Characterising non-urgent users of the emergency department (ED): a retrospective analysis of routine ED data. \u003cem\u003ePLoS One\u003c/em\u003e. 2018;13(2):e0192855. [cited 2024 Dec 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0192855\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0192855\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoon J, Cordasco KM, Chow A, Rubenstein LV. The relationship between same-day access and continuity in primary care and emergency department visits. \u003cem\u003ePLoS One\u003c/em\u003e. 2015;10(9):e0135274. [cited 2024 Nov 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0135274\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0135274\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCowling TE, Cecil EV, Soljak MA, Lee JT, Millett C, Majeed A et al. Access to primary care and visits to emergency departments in England: a cross-sectional, population-based study. \u003cem\u003ePLoS One\u003c/em\u003e. 2013;8(6):e66699. [cited 2024 Oct 06]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0066699\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0066699\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurray M, Tantau C. Must patients wait? \u003cem\u003eJt Comm J Qual Improv\u003c/em\u003e. 1998;24(8):423\u0026ndash;5. [cited 2025 Aug 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0--S1070324116303923/first-page-pdf\u003c/span\u003e\u003cspan address=\"https://www.sciencedirect.com/sdfe/pdf/download/eid/1-s2.0--S1070324116303923/first-page-pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurray M, Tantau C. Same-day appointments: exploding the access paradigm. \u003cem\u003eFam Pract Manag\u003c/em\u003e. 2000;7(8):45\u0026ndash;50. [cited 2025 Aug 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aafp.org/pubs/fpm/issues/2000/0900/p45.html\u003c/span\u003e\u003cspan address=\"https://www.aafp.org/pubs/fpm/issues/2000/0900/p45.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ede Gusm\u0026atilde;o Bonilla PP, Wollmann L. Avalia\u0026ccedil;\u0026atilde;o da implanta\u0026ccedil;\u0026atilde;o do acesso avan\u0026ccedil;ado nos indicadores de qualidade de uma unidade de sa\u0026uacute;de. \u003cem\u003eRev Bras Med Fam Comunidade\u003c/em\u003e. 2020;15(42):2360. [cited 2025 Aug 19] Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5712/rbmfc15(42)2360\u003c/span\u003e\u003cspan address=\"10.5712/rbmfc15(42)2360\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePinto AR, Oliveira LGF, Fracolli LA, Nichiata LYI. Bases de implanta\u0026ccedil;\u0026atilde;o e pilares de sustenta\u0026ccedil;\u0026atilde;o do Acesso Avan\u0026ccedil;ado: convite ao debate. \u003cem\u003eSa\u0026uacute;de Debate\u003c/em\u003e. 2025;49:e10134. [cited 2025 Aug 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/2358-2898202514610134P\u003c/span\u003e\u003cspan address=\"10.1590/2358-2898202514610134P\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKraaijvanger N, Van Leeuwen H, Rijpsma D, Edwards M. Motives for self-referral to the emergency department: a systematic review of the literature. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2016;16(1):685. [cited 2024 Nov 30]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-016-1935-z\u003c/span\u003e\u003cspan address=\"10.1186/s12913-016-1935-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan den Berg MJ, Van Loenen T, Westert GP. Accessible and continuous primary care may help reduce rates of emergency department use. An international survey in 34 countries. \u003cem\u003eFam Pract\u003c/em\u003e. 2016;33(1):42\u0026ndash;50. [cited 2024 Dec 02]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/fampra/cmv082\u003c/span\u003e\u003cspan address=\"10.1093/fampra/cmv082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTurrini RNT, Lebr\u0026atilde;o ML, Cesar CLG. Resolutividade dos servi\u0026ccedil;os de sa\u0026uacute;de por inqu\u0026eacute;rito domiciliar: percep\u0026ccedil;\u0026atilde;o do usu\u0026aacute;rio. \u003cem\u003eCad Sa\u0026uacute;de P\u0026uacute;blica\u003c/em\u003e. 2008;24:663\u0026ndash;74. [cited 2024 Sep 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S0102-311X2008000300020\u003c/span\u003e\u003cspan address=\"10.1590/S0102-311X2008000300020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency medical services, Health services misuse, Brazil","lastPublishedDoi":"10.21203/rs.3.rs-7999517/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7999517/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThis study aimed to analyze the utilization profile of an emergency department (ED) in a Brazilian capital by identifying patients' sociodemographic characteristics, reasons for seeking care, and the appropriateness of ED use.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional study was conducted over 30 consecutive days between November and December 2019. A total of 1,177 users aged 18 or older were interviewed using a structured questionnaire and selected through systematic random sampling. Data were analyzed using Stata 17, estimating prevalence and 95% confidence intervals (95%CI). The Hospital Urgency Appropriateness Protocol (HUAP) was used to assess inappropriate use.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eED use was more frequent among young adults (57.8%; 95% CI: 54.9\u0026ndash;60.6), women (62.4%; 95% CI: 59.5\u0026ndash;65.1), mixed race individuals (55.0%; 95% CI: 52.1\u0026ndash;57.8), socioeconomic class C (58.4%; 95% CI: 55.5\u0026ndash;61.2), those with a high school education (44.7%; 95% CI: 41.9\u0026ndash;47.5), without private insurance (87.4%; 95% CI: 85.1\u0026ndash;89.4), married (48.2%; 95% CI: 45.3\u0026ndash;51.0), and with good self-rated health (44.5%; 95% CI: 41.7\u0026ndash;47.4). Most sought care directly (71.7%; 95% CI: 69.0\u0026ndash;74.2) and were classified as low-urgency cases (73.0%; 95% CI: 70.4\u0026ndash;75.5), although 76.2% (95% CI: 73.6\u0026ndash;78.5) perceived their condition as urgent. Additionally, 73.2% (95% CI: 70.6\u0026ndash;75.6) stated they would not have visited the ED if they could have had a primary health care (PHC) appointment the following day. Among those perceiving low urgency, 28.7% (95% CI: 23.5\u0026ndash;34.4) chose the ED believing it to be more effective. Among those who had sought care elsewhere previously, 53.2% (95% CI: 47.8\u0026ndash;58.6) migrated to the ED due to dissatisfaction with PHC. Inappropriate use occurred in 29.3% (95% CI: 26.7\u0026ndash;32.1).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eDirect demand for ED services and challenges in primary care highlight the need to strengthen PHC. Improving access to and quality of PHC could reduce unnecessary ED visits, enhance service efficiency, and support a more sustainable healthcare system.\u003c/p\u003e","manuscriptTitle":"Profile of Emergency Service Use in a Brazilian Capital City","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-03 11:19:35","doi":"10.21203/rs.3.rs-7999517/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-27T21:36:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-16T20:20:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330348942952063780786958704512348690051","date":"2025-12-05T20:03:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-04T03:23:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244720820020511646270297375839811245928","date":"2025-12-03T00:22:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68965522871754362949413070095636047633","date":"2025-12-01T01:29:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-30T18:50:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-04T20:06:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-03T17:55:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-03T17:54:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-10-31T14:31:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8fc9c422-f995-4049-acba-73aef2c2f96c","owner":[],"postedDate":"December 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-03T11:19:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-03 11:19:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7999517","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7999517","identity":"rs-7999517","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}