Emergency service user profiles: patterns and inappropriate use in a southern Brazilian cohort, 2021-2022

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Inappropriate use and reuse play an important role in this phenomenon. However the literature on the patterns of reuse and how personal an regional health system characteristics influence it is still scarce. Therefore, this study aimed to investigate reuse patterns and its determinants. Methods This prospective cohort study investigate EMS overuse and inappropriate use in Pelotas city, Brazil (2021–2022). 2909 patients were followed for one year. Results 61% of patients reused the service, with 25.5% classified as frequent users (FU), accounting for 57.4% of total visits. Hyperusers (≥ 10 visits/year) represented 3.9% of patients, but 14.2% of total visits. FU were more prevalent among women, while “hyperusers” were associated with young adults, “18 to 49 years”. In analyzing the appropriate use criterias, a total of 20.6% of visits were classified as inappropriate, though no significant difference existed across use patterns. Conclusion The results suggest the need for new studies, looking for population patterns in the profiles of emergency service users, based on frequency of use. From this, it will be possible to base public policies that interfere with the phenomenon. Frequent users Inappropriate use Use patterns Emergency Service Emergency Service Misuse Introduction Studies indicate an annual increase in demand for Emergency Medical Services (EMS) worldwide 1,2 , varying between 3% and 6% in a year 3 . However just a small portion of it requires immediate medical intervention 4 , which represents one of the EMS overcrowding causes. This phenomenon is observed in countries with different socio-economic realities, different health systems and different intensities around the world 5 . That results in serious consequences to health services, like the worsening of the service quality 6 , dissatisfaction with the service on the part of users or workers 7–10 and may lead to inappropriate support to truly urgent conditions 11 . Another important consequence of EMS overcrowding is the increase of the already high operating cost 12 threatening health system sustainability 4 . The EMS inappropriate use is also related to a high cost increase in this scenario, because presents an important avoidable cause to overcrowding 13–15 . There is no consensus on the definition of inappropriate use, some of which conflict with each other 16 . Health professionals tend to consider inappropriate use as something that could be better resolved in other care settings, especially Primary Health Care (PHC) 17 . Another point of view that has been discussed is whether or not to get immediate attention. Consults that could have been postponed for 24 hours, without adding up risk to patients, have been treated like inappropriate 4,18 . Both concepts are linked to fundamental problems: the perception of superiority and resolubility from the EMS above PHC 16 and a mistaken self-perception of the severity of the symptoms presented, leading to a hasty search for a service with a greater diagnostic repertoire and medical interventions 15,17,19,20 . The reported prevalence of inappropriate EMS use ranges from 10.0–90.0% 17,21 , depending on the criteria established for the evaluation, as there is no consensus on the definition. Within this problem, the frequency of EMS use seems to be a fundamental discussion to understand the consequences over the health services and systems. Literature lacks a standardized definition for the cut-off point to analyze this phenomenon, varying between ≥ 3 to ≥ 20 visits per patient in a year 17 . However, a cut-off point of ≥ 4 episodes per year per patient has been widely used to analyze the frequent users (FU) of EMS 15 . The FU have already been associated with a higher risk of hospitalization, of functional decline, of complications during treatment/procedures and higher mortality between ESM patients 22–25 . Although numerically they represent a small portion of the population that uses EMS, FU have already been associated with a large portion of the total cost of these services 26–28 , and it may require a cost of 24.0% of the service budget to serve the 1.0% of the most frequent users 29 . Despite Brazil's Urgent and Emergency network being costly to the “Sistema Único de Saúde” (SUS), national healthcare universal system, there were few primary studies realizing the impact of inappropriate use to our services and our health system 30–35 . In Pelotas, in the extreme south of Brazil, there was a pioneering study in 2004 to investigate the issue of inappropriate use and characteristics of use in a single EMS 30,34 . After 17 years, in 2021, a new cohort study was designed to better understand and measure the impact of this phenomenon on the city's only public EMS 36 , entitled “Machine learning analysis to predict health outcomes among emergency department users in Southern Brazil” - it’s being used “Saúde da População do Pronto Socorro” (SPPS) as a short name for this study. Based on these data, this paper evaluated the reuse profile of Pelotas city Emergency Service (PSP) users, in a year, from the frequency of this service use and its intersection with the inappropriate use of EMS by the perspective of a protocol validated in Brazil 37 . This was designed to respond to the hypothesis that there are different patterns of PSP reuse by population, influenced by different variables of personal profile and the regional health system dynamics. Methods Design and sample The SPPS is a prospective cohort aiming to evaluate reutilization and associated factors on patients admitted to the PSP in a medium-size city in the southeast Brazil between may 2021 and august 2022. The baseline data collection took place between May and August 2021 through a survey carried out on patients admitted to the PSP by a team of hired researchers, composed of health professionals and undergraduate health students. In 2022, using PSP internal data, the second study step was realized, investigating the service reutilization by first step volunteers between August 2021 and August 2022. Subsequently, a quality control with 10% of the sample was conducted, by phone, evaluating whether the answers from the baseline remained consistent with what the patient would currently answer. Following the removal of losses, refusals, and duplicates, the final sample size was calculated, the final sample was 2909 (Flowchart 1). The design study and the sample calculation had been outlined and proposed to take place before the COVID-19 pandemic. As the pandemic was still ongoing during baseline collection in 2021, the number of collected interviews were lower (n = 4365) than stipulated (n = 4892) to analyze all the proposed outcomes (Flowchart 1).The cause of this lower data collect was probability the change of the PSP dynamic after a municipal flu syndrome emergency service setted up in Pelotas. Flowchart 1 - Flowchart of eligible patients for monitoring in SPPS Inclusion and exclusion criteria The inclusion criteria were age ≥ 18 years and seeking care at the PSP. The exclusion criteria were age ≤ 18 years, clinical emergency admission in the emergency room by municipal ambulances or Mobile Emergency Service (SAMU), patients taken for forensic procedures and carriers patients of severe communication deficit condition. Reutilization subgroups Our analyses were stratified according to EMS reutilization frequency pattern: “non-reusers”, “users”, “regular users” and “hyperusers”. We considered “non-reusers” as patients who didn’t use the emergency in a year. “Users” as patients whose pattern of EMS use varied between ≥ 1 or ≤ 3 utilizations in a year. “Regular users” as patients whose pattern of EMS use varied between ≥ 4 or ≤ 9 utilizations in a year. “Hyperusers” as patients whose pattern of EMS use was ≥ 10 utilizations. This last group was created because, to do the baseline collection, we programmed the RedCap to accept at most 10 utilizations in a year per patient. Therefore, we created a separate subgroup for this pattern, as we cannot determine whether each hyperuser used the service 10 or more times. Notably, the literature defines FU as the sum of the “regular users” and “hyperusers” groups. Sociodemographic variables We used the following sociodemographic variables: gender, age, skin color and schooling. Participants self-identified their gender as male or female. Age was collected in complete years and categorized into three subgroups: equal 18 or ≤ 39 years old, ≥ 40 or ≤ 59 years old and ≥ 60 years old. Participants self-identified their skin color as white, black or brown/yellow/indigenous, which were analyzed together. About schooling, the possible answers were: can't read/didn't study, collected separately, but analyzed jointly in this study; incomplete elementary school; complete elementary school or incomplete high school, collected separately, but analyzed jointly in this study; complete high school or incomplete higher education, collected separately, but analyzed jointly in this study; and complete higher education or more degrees, collected separately, but analyzed jointly in this study. Health self-perception, severity and symptoms onset Patients' self-perception of their health was assessed in terms of symptom duration, self-perception of severity and need for immediate treatment, and general self-perception of health. About symptom time onset, patients could choose from the options: less than 1 day, less than 1 week, more than 1 week, less than 1 month and more than 1 month. About self-perception of severity and need for immediate treatment, the patient could answer whether or not they thought they needed care. Patients rated their general health as: “very bad” or “bad”, collected separately but analyzed together in this study, “fair”, and “good” or “excellent”, collected separately but analyzed together in this study. Inappropriate use As episodic criteria for EMS inappropriate use, we used criteria from a Spanish protocol already validated in Brazil 37,40 , and assessed severity criteria, diagnostic intensity criteria, treatment criteria, “other criteria” and spontaneous consultation criteria. The presence of at least one or the complete absence, “yes” or “no”, of the following severity criteria were considered: loss of consciousness, disorientation, coma, instability, numbness, sudden loss of vision or hearing, pulse changes ( 140 beats per minute), arrhythmias ( 140 beats per minute), blood pressure changes (systolic 200 and diastolic 120), changes in electrolytes or blood gases, active bleeding and loss of functional capacity of any part of the body. As the criteria already present, the presence of at least one or the complete absence of the following diagnostic intensity criteria were considered: constant monitoring of vital signs every 2 hours, radiography of any kind, laboratory tests and electrocardiogram - except for known heart diseases who consult for reasons unrelated to the disease. The presence of at least one or the complete absence of the following treatment criteria were taken into account: administration of medication or intravenous fluid, administration of oxygen, placement of a plaster cast (except bandages). “Other criteria” included the presence of at least one or the complete absence of: the need for a 12-hour observation stay in the emergency department and hospitalization or transfer to another department. Lastly, we considered the presence of at least one or the complete absence of the following criteria for spontaneous consultation: patient coming from an accident and requiring medical assessment, symptoms that indicate vital urgency (chest pain, chest tightness and acute abdominal pain), previous health condition that usually requires hospitalization, doctor's advice that the patient go to the emergency room because of these symptoms, need for urgent medical care and the EMS is the closest place, and other spontaneous consultation criteria determined by the doctor who attended the patient. To the search for care in EMS to be considered as an inappropriate use of the service, the patient couldn’t present “positive” for any of the five criteria described above. Finally, the color of the triage bracelet was recorded based on the adapted Manchester Triage Scale (MTS), which is used by the service. The blue and green bracelets are for patients who are not serious enough to require immediate care; yellow for those with some dysfunction, but not life-threatening in the short term; and red, which indicates dysfunction requiring immediate care due to the risk to life. Pelotas and the Municipal Emergency Service According to the 2022 Annual Management Report of the Municipal Health Department of Pelotas - Rio Grande do Sul, Pelotas is a city of less than 350,000 inhabitants. Data from 2021 from the Brazilian Institute of Geography and Statistics showed that the city ranked 413th in terms of Gross Domestic Product per capita out of 497 municipalities in RS, making it one of the cities with the poorest population in the state. In healthcare terms, the city serves as a reference for approximately 1 million people across the 3rd and 7th Regional Health Coordination areas 38 . The Pelotas Emergency Room (“PSP”, in Portuguese), the city's sole public hospital emergency department, received 47,784 and 65,056 visits respectively in 2021 and 2022. Statistical analysis The data were analyzed through the Stata statistical software version 15.0 (Statacorp., College Station, TX, USA). An initial descriptive analysis of the reuse data was conducted to characterize the sample. Categorical variables were reported as relative frequencies, using a confidence interval (CI) by 95%. The chi-squared test was applied to assess differences between categorical variables. A 5% significance level was established for all statistical analyses. Ethics All methods were carried out in accordance with the Declaration of Helsinki and Regulations by Brazilian National Committee of Ethics in Research. The study was approved by the Institutional Review Board of the Federal University of Pelotas' Faculty of Medicine (FAMED-UFPel) in March 2020 (CAAE: 17785219.1.0000.5317). Study protocol details are published elsewhere 36 . Results It was realized the evaluation of the sample reuse (n = 2909) one year after the baseline. There was reused by 61.0% (n = 1776) of participants 39 , as previously published, accounting for 4935 searches for medical care in the PSP (Table 1 ). The “non-reusers” of service in a year were 1133 study participants. The “users” subgroup of the service accounted for 74.4% (72.4–76.4%, CI 95%) of reusers and 42.7% of use (Table 1 ). Regarding “regular users”, this subgroup represents 21.6% (19.8–23.6%, CI 95%) of the sample, corresponding to 43.2% of total service utilization (Table 1 ). “Hyperusers”, chronic users of service, accounted for 3.9% (3.1-5.0%, CI 95%) of reusers and at least 14,2% of total utilization (Table 1 ). Then, we were able to calculate that frequent use was 25.5% of the sample, accounting for 57.4% of the PSP uses recorded. Table 1 Percentage of PSP reusers and PSP reutilization by each reutilization pattern subgroup. Reutilization in a year Percentage of reusers (N = 1776) %, 95% CI Percentage of total use Analyzed visits = 4935 % 1 41.9 (39.7–44.3) 15.1 2 20.9 (19.1–22.9) 15.1 3 11.6 (10.2–13.2) 12.5 4 7.5 (6.4–8.9) 10.9 5 5.0 (4.0–6;1) 8.9 6 3.1 (2.4-4.0) 6.7 7 2.9 (2.2–3.8) 7.4 8 2.0 (1.4–2.7) 5.7 9 1.1 (0.7–1.7) 3.6 10 or more 3.9 (3.1-5.0) 14.2 Regarding sociodemographic stratification, we found a tendency of higher prevalence of FU among women, representing 58.8% (53.8–63.7%, CI 95%) of “regular users” and 62.9% (50.9–73.3%, CI 95%) of “hyperusers” (Table 2 ). “Non-users” were more often males, approximately 55.0% (52.1–57.9%, CI 95%), and there was no difference between the genders among “users”. Regarding age, at appropriate use groups, despite the fact that there was a tendency to older patients, “60 years or more”, have a higher prevalence, just “users” presented significant statistical differences (40.7%; 38.1–43.4%, CI 95%). Among “hyperusers”, on the other hand, there was a high prevalence of use in the “18 to 39 years” group, representing 55.7% (43.9–66.9%, CI 95%). Between "hyperusers", patients aged "18 to 39 years" presented a higher prevalence than the general presented in the study sample, 32,2%, as already published 39 . Regarding skin color, white was the most prevalent skin color across all, being numerically higher among “non-users” (78.3%) and lower among “hyperusers” (67.1%). Among “hyperusers”, the lower prevalence of use among white-skinned interviewees occurred at the expense of a greater increase in this pattern of use among “brown/yellow/indigenous” (14.3%; 7.8–24.6%, CI 95%), however, there wasn’t statistical significance in the confidence intervals. Between "users", patients who self-reported as “black” presented a higher prevalence than the general presented in the study sample, 15.6%, as already published 39 . No significant differences (p = 0.993) in educational level were observed to use pattern, with the most of the sample presenting “Incomplete elementary school”. CI: Confidence Interval; ES: Elementary School; HS: High School; HE: Higher Education About using profile stratification related to self-rated health, it was observed that across groups the symptoms that led to the use of the service had arisen less than a day (Table 3 ). In contrast, “non-users” and “users” showed a numerically higher prevalence (48.5% and 43.5%, respectively) than the FU group, in which no statistical significance was observed (Table 3 ). With regard to self-assessed health severity at this care-seeking episode, all utilization profiles showed a prevalence more than 92.3% among patients self-perceiving their condition as serious and in need of immediate care (Table 3 ). A curious fact was that 100.0% of “hyperusers” reported needing immediate care and treatment (Table 3 ). Finally, with regard to self-rated health in general, 47.9% of “non-users” considered their health to be “good/ excellent”, presenting statistical significance (44.9–50.9%, IC 95%) (Table 3 ). Although “hyperusers” tended to consider their health as “very bad/bad” (37.5%), there wasn’t statistical significance (26.5–50.0%, IC 95%) (Table 3 ). Table 3 EMS use patterns stratification and self perception of health Non-reusers % 95%CI Users % 95%CI Regular Users % 95%CI Hyperusers % 95%CI P-value Sample Symptom time onset N = 1065 N = 1261 N = 366 N = 69 P < 0,001 N = 2761 Less than 1 day 48.5 (45.5–51.5) 43.5 (40.8–46.3) 34.7 (30.0-39.7) 37.7 (27.1–39.7) Less than 1 week 26.0 (23.5–28.7) 28.4 (26.0–31.0) 32.2 (27.6–37.2) 36.2 (25.7–48.2) More than 1 week 11.4 (9.6–13.4) 11.7 (10.0-13.5) 10.9 (8.1–14.6) 4.4 (1.4–12.7) Less than 1 month 3.6 (2.6–4.8) 3.7 (2.8–4.9) 5.8 (3.7–8.6) 2.9 (0.1–11.0) More than 1 month 10.5 (8.8–12.5) 12.7 (11.0-14.6) 16.4 (12.9–20.5) 18.8 (11.2–29.9) Severity self-perception and need for immediate treatment N = 1100 N = 1288 N = 374 N = 68 P = 0,001 N = 2830 Yes 92.3 (90.5–93.7) 94.9(93.5–96.0) 96.8 (94.4–98.1) 100 No 7.7 (6.3–9.5) 5.1 (4.0-6.5) 3.2 (1.8–5.6) 0 Health self-perception N = 1066 N = 1213 N = 354 N = 64 P < 0,001 N = 2697 Good/excellent 47.9 (44.9–50.9) 40.0 (37.0-42.9) 30.0 (25.4–35.0) 17.2 (9.7–28.5) Fair 37.7 (34.8–40.7) 41.5 (38.7–44.3) 47.0 (42.0-52.4) 45.3 (33.5–57.6) Very bad/bad 14.4 (12.4–16.6) 18.5 (16.4–20.7) 23.0 (18.8–27.5) 37.5 (26.5–50.0) CI: Confidence Interval Regarding use profile stratification related to severity criteria, there was a total prevalence of inappropriate use among the studied population of 20.6% (n = 2543). However, there wasn't a statistically significant difference between the use profiles (P = 0,300) (Table 4 ). In terms of the MTS, all groups had a high prevalence of “yellow” screening, ranging from 84.9% for “non-users” to 89.5% for “regular users”. “Non-reusers” had the highest prevalence of “red” (8.7%; 7.2–10.6%, CI 95%). Table 4 – EMS use patterns stratification, criteria for appropriate use and triage based on adapted MTS. Non-reusers % 95%CI Users % 95%CI Regular users % 95%CI Hyperusers % 95%CI P-value Sample Severity criteria N = 1013 N = 1130 N = 343 N = 59 P = 0.004 N = 2545 Yes 34.2 (31.3–37.1) 28.9 (26.4–31.7) 26.8 (22.4–31.8) 42.4 (30.4–55.3) No 65.8 (62.9–68.7) 71.1 (68.3–73.6) 73.2 (68.2–77.6) 57.6 (44.7–69.6) Diagnostic and intensity criteria N = 968 N = 1049 N = 306 N = 56 P = 0.180 N = 2379 Yes 57.4 (54.3–60.5) 55.9 (52.8–58.8) 54.6 (48.9–60.0) 69.6 (56.3–80.3) No 42.6 (39.5–45.7) 44.1 (41.2–47.2) 45.4 (40.0–51.0) 30.4 (19.7–43.6) Treatment criteria N = 965 N = 1045 N = 306 N = 56 P = 0.016 N = 2372 Yes 53.3 (50.1–56.4) 46.7 (43.7–49.7) 46.4 (40.9–52.0) 53.6 (40.4–66.2) No 46.7 (43.6–49.9) 53.3 (50.3–56.3) 53.6 (48.0-59.1) 46.4 (33.8–59.6) Other criteria N = 965 N = 1050 N = 309 N = 56 P = 0.038 N = 2380 Yes 27.1 (24.4–30.0) 29.1 (26.5–32.0) 30.1 (25.2–35.4) 44.6 (32.1–15.9) No 72.9 (69.9–76.6) 70.9 (68.0-73.5) 69.9 (64.5–74.9) 55.4 (42.1–67.9) Spontaneous consultation criteria N = 966 N = 1087 N = 331 N = 58 P = 0.426 N = 2442 Yes 46.8 (43.7–49.9) 44.2 (41.3–47.0) 45.6 (40.3–51.0) 53.4 (40.5–65.9) No 53.2 (50.0-56.3) 55.8 (52.8–58.7) 54.4 (49.0-59.7) 46.6 (34.1–59.4) Inappropriate use of EMS N = 1012 N = 1129 N = 343 N = 59 P = 0.300 N = 2543 Yes 80.2 (77.7–82.6) 77.8 (75.2–82.6) 80.8 (76.2–84.6) 84.8 (73.0–92.0) No 19.8 (17.4–22.3) 22.2 (19.9–24.7) 19.2 (15.4–23.7) 15.2 (8.0-26.9) Adapted MTS N = 1076 N = 1272 N = 371 N = 70 P = 0.003 N = 2789 Blue 2.5 (1.7–3.6) 1.7 (1.1–2.6) 0.8 (0.3–2.5) 1.4 (0.2–9.6) Green 3.8 (2.8–5.1) 5.7 (4.5–7.1) 5.9 (3.9–8.9) 8.6 (3.9–17.9) Yellow 84.9 (82.7–87.0) 85.8 (83.7–87.6) 89.5 (85.9 92.2) 88.6 (78.7–94.2) Red 8.7 (7.2–10.6) 6.8 (5.6–84) 3.8 (2.3–6.3) 1.4 (0.2–9.6) CI: Confidence Interval Discussion This prospective cohort study evaluated PSP EMS reuse over one year and its potential determinants. We found that FU, "regular users" and "hyperusers", comprising 25.5% of the sample, accounted for 57.4% of all recorded EMS uses. Inappropriate use was identified in 20.6% of the sample, with no significant differences in reuse patterns between groups. The MTS categorization indicated overestimation of severity according to PAHU criteria. Perceiving symptoms as severe and requiring immediate treatment appeared to influence inappropriate use. These and other research findings will be discussed in the following subsections. EMS reuse and reuse patterns Three Brazilian primary studies evaluated the prevalence of EMS reuse 30,32,34,35 . One of them was a cross-sectional study conducted in Pelotas in 2004, also in PSP 30,34 , which found a self-reported FU of 20.0%. In addition, it pointed out that 5.9% of the sample self-reported using the EMS in three or more episodes in the last three months. The study did not show the total prevalence of reuse in the service. Another Brazilian cohort, conducted in Ouro Preto, Minas Gerais, in 2012 32 , evaluated an Emergency Care Unit (“UPA”, in Portuguese) through medical records during a year. It pointed out to a FU prevalence by 16.4% of the sample and described that more than a half of the patients reused the service in a year. The study did not show the total prevalence of reuse in the service. Finally, the third study 35 was conducted at a single EMS in Vitória, Espírito Santo, during December 2019, targeting individuals aged between 18 to 39 years old. This study showed a self-reported reuse of 85.1% and frequent use of 49.3% in the sample. Comparing the findings from SPPS to CARRET et al. 30,34 , a significant difference in FU prevalence was observed between the studies. Even though more emergency services have been created in Pelotas over the past 17 years and the SPPS is no longer the only public emergency in the city, the higher prevalence found by us suggests two possible interpretations: either there has been a worsening in access to PHC or self-reported reuse was influenced by memory bias. The Ouro Preto study 32 , conducted in a UPA, on the other hand, showed a FU prevalence approximately 35.0% lower than that recorded in the SPPS. A possible explanation lies in differing factors influencing inappropriate emergency use in different care settings. About studies from other countries, a 2021 Italian multicenter study 41 , also conducted during the cooling-off period of COVID-2019 pandemic, presented a total EMS reutilization of 22,8% of the sample. Applying the same criteria for FU as our study, revealed a FU prevalence of 2,9% of the sample, with these patients accounting for 11,9% of all uses. A EMS Portuguese single-center cohort 42 rated by similar criteria, “regular users” as those with between 4 and 10 uses in a year and “hyperusers” as those with 10 or more utilizations in a year. “Regular users” represented 5.3% of the sample, accounting for 17.5% of health consultations, while “hyperusers” represented 0.3% of the sample and accounted for 3.0% of medical consultations. We can see how significant the data we found on the Pelotas service in 2021 was. Despite the underestimation of actual reuse in the service, there were approximately 8.8 times more FU and 4.8 times more uses by FU than in the Italian study 41 . Regarding “hyperusers” and “regular users” in the Portuguese study 42 , although the criteria were slightly different, we found a prevalence 13 times higher for “hyperusers” and they were proportionally responsible for 4.9 more emergency visits. Comparing “regular users”, we found 4.3 times more patients using this pattern in EMS, accounting for 2.4 more consultations. A 2006 North American study 43 showed that 63.0% of the sample reused EMS, and 8.0% of frequent users were related to 28.0% of medical care. These findings were very similar to those evaluated by the SPPS, with a prevalence of reuse of 61.0% 39 and with the 7.0% of frequent users representing 22.8% of users. Notably, the North American health system contributes to inappropriate service use, as uninsured individuals seek care in these settings 43 . This should not happen in a universal and public health system such as the SUS. Some studies suggest that just PHC access may not be enough to control chronic diseases in patients who frequently use emergency services, as the follow-up rate in PHC is lower than necessary for these patients 44,45 . EMS FU also frequently uses non-emergency health services 46,47 . Despite PHC access, non-life-threatening acute illnesses are often bypassed in favor of direct emergency room consultation, due to greater trust in this environment, which may be the key to inappropriate use 3 . This relationship was corroborated by a study 49 showing inappropriate use linked to trust in hospital services and distrust in PHC quality, reaching 65.1% of inappropriate use for this reason in the sample. EMS reuse pattern and sociodemographic criteria The SPPS identified a tendency toward FU among women and “hyperuse” among young adults, “18 to 39 years”. To the best of our knowledge no Brazilian study focused on sociodemographic criteria and EMS use patterns. The Piracicaba primary study 31 , conducted in two of four city’s UPA’, found a 2,6 major rate by 60 or more years of population to be screened like “blue”, categorized as non-urgent. On the other hand, the Guarapuava study 33 , conducted in two city's UPAs, identified a strong link between EMS misuse and pediatric patients (0–17 years). Finally, in the Vitória study 35 , there wasn't a statistically significant difference between gender and inappropriate use, educational level and inappropriate use or skin color and inappropriate use. FURIA et al. 41 showed a tendency for FU to be more prevalent among women (53.9%), as corroborated by the literature 43 and observed in SPPS. Furthermore, in the Italian study, in terms of age, male FUs tended to be older (56.5 years old on average) than non-FUs (52.3 years old on average); no difference existed between female FUs and non-FUs (56.2%). Similarly, Portugal 42 reported higher inappropriate use among women. No prior studies examined age and self-reported skin color's impact, as we did. EMS reuse pattern and health self-perception Two out of five Brazilian studies assessed patients' health self-perception. However, none examined reuse from this perspective. As for the start of symptoms, the study by SOUZA. 31 found that 65.2% of patients started having the symptoms that brought them to the EMS less than three days ago. CARRET et al. 34 , in contrast, found that 40.7% of patients sought EMS care on the same day of symptom onset, while 12.0% waited more than 10 days after symptom onset. Regarding health self-perception, CARRET et al. 30 reported that 46.5% rated their health as 'bad' and that, in this current episode, 70% considered needing emergency care. SOUZA et al. 31 , however, pointed out that in her study 59.0% of the patients considered their health to be “satisfactory”, with 71.4% requiring care during this episode. CARRET et al. 34 indicated that self-perceived health was a poor predictor of the need for emergency care, with low specificity (37.0%). SOUZA et al. 31 concurred showing a 9,8 greater chance of patients with a self-perception of emergency being screened as “blue”, the non-emergency bracelet. The literature has already demonstrated that self-perceived severity of the condition is directly associated with emergency service utilization 3,50 . Anxiety in the face of symptoms seems to be a key point in unraveling the episodic inappropriate use of EMS 3,48 . SPPS findings may elucidate the relationship between FU or appropriate use and symptoms onset. The symptom onset was typically “less than one day” across appropriate use patterns, but there was no statistical significance between FU patterns. This may indicate the tendency for appropriate use patterns to be, in fact, related to acute symptoms, while FU patterns seek care in EMS in an eradicative way, including for chronic symptoms that are better managed by PHC. About Self-perception of severity and need for immediate treatment, more than 92,3% of the SPPS sample considered that his condition was severe and required immediate treatment in all groups, which is in line with what is debated about anxiety, the difficulty of critically self-assessing the real severity of symptoms and the ability to self-refer to the correct health environment within the country's health system. Furthermore, deteriorating self-perceived health was linked to EMS hyperutilization. Finally, about general self-perception of health, EMS reuse pattern and inappropriate EMS use The SPPS found that inappropriate use was identified in 20.6% of the sample, with no significant differences in reuse patterns between groups. The MTS revealed over 90% compatibility with emergency environments criterias, being categorized as “yellow” or “red”. However, the screenings as "blue" and "green" combined, in all groups, varied between 6.3 and 10.0%, indicating overestimation of severity according to PAHU criteria. The other five Brazilian studies assessed the EMS misuse using the PAHU protocol 40 or its derivatives 31,32 , but none of them associated the inappropriate use with reuse patterns. The studies from Pelotas 34 and from Vitória 35 found, respectively, a prevalence of 24.2% and 30,6% of municipal hospital emergency users who didn’t meet any of the criteria for adequate EMS use, constituting inadequate use. The other three studies were carried out in UPAs and found an inadequate use of more than 45% in one of them based on different criteria: adapted PAHU 32 , indicators of inappropriate use found in a systematic review 33 and "blue" screening 31 . These findings made us question whether the criteria for inappropriate use of EMS should be the same for different health care contexts, such as UPA and hospital emergency. In the Italian study 41 , logistic regression showed an inversely proportional relationship between appropriate use and FU, with UF being three times more likely to be classified as non-urgent than non-FU. In this sample 76.2% of FU and 73.0% of non-FU were classified as inappropriate use. The criteria used in this study for appropriateness were indication for hospitalization and death. The classification in triage by the nursing team was also taken into account, with FU patients classified with blue presenting three times more classified as non-urgent use than non-FU patients. Another study, conducted in the United States 51 , found a prevalence of 3.3% of inappropriate use, based on the criterion that misuse is when complementary diagnostic tests, procedures or treatments were unnecessary. These were mainly related to psychiatric disorders and dental conditions. A French cross-sectional study 20,68 found 2.0% of non-urgent patients willing to be redirected to PHC. 23.5% However, wanted to be guaranteed an appointment and requested that this unit be close to a hospital and 17.6% would like the emergency doctor to agree with this. The location of primary care, the journey to it, guaranteed access, and confirmation that these symptoms are not life-threatening are relevant factors influencing population choices between PHC and EMS. Primary Care Sensitive Conditions (“CSAP”, in Portuguese) serve as indicators in Brazilian hospital care, which points to clinical conditions that could have been managed in PHC, except in cases of exacerbation of the chronic condition 52 , linked to EMS misuse in Brazil 33 . Other international studies support that inappropriate use stems from demanding care better suited to PHC or specialty clinics 17,53–55 . Enhancing PHC with imaging technologies appears promising, it can become even more resolutive to increase resolution from a medical perspective. A Romanian study found 27.9% of non-urgent visits could be managed in PHC if there had been access to electrocardiogram and point-of-care ultrasonography 20 . A systematic review 17 found that patients who spontaneously sought emergency services were 30.0% more likely to have inadequate use of the service 17 . Regarding triage, a study conducted during the COVID-19 pandemic indicated that patients with “green” triage were 4 times more likely to have inappropriate use when compared to those triaged as “yellow” 49 . This study also identified a significant inclination towards misuse among young individuals, with no gender-related association. According to the Pelotas Health Department 38 , 23.0% of consultations at the PSP were considered “green” or ”blue”, proportionally much lower than that found in our study. One possibility for this may have been the exclusion criteria for pediatric patients, who are more related to the use of emergencies for conditions that are sensitive to primary care 33 , justifying their classification with a lower degree of emergency by triage. Limitations The COVID-19 pandemic has resulted in a global decline in EMS demand, with demand decreasing by up to 50% in certain countries 56–58 . In Pelotas, data from the Pelotas Health Department 38 pointed to a process of normalization of PSP care, showing consistent demand growth between 2021 and 2022, after the closure of specialized care for flu-like syndromes 38 , causing patients to return to PSP usage. Even though the Covid-19 pandemic has led to a lower “n” than expected for the baseline, due to the magnitude of the phenomenon of inappropriate use within the PSP, we consider our data as representative of the service. In addition, a possible bias for our study was that patients admitted by ambulance and SAMU were not allowed to participate in our survey, as they were automatically screened with a red bracelet. However, they were eligible for the study if, after stabilizing, they remained under clinical observation in the emergency room. We believe that, although the exclusion of red cards may be a bias, its effect may not have been relevant due to the possibility of these patients' inclusion after clinical stabilization. Finally, in order to fully understand the phenomenon in the city, we need to evaluate other emergency care settings, such as UPA and private EMS. We must reiterate that the method used to record the group of “hyperusers”, as explained in the study's methodology, leads us to underestimate the impact of this population on the results presented in this study. Despite this limitation, as explained in the discussion, when we compare the results of our analysis with the data found in the literature, there is a magnitude of frequent use and inappropriate use that is consistent with what has already been discussed. Conclusion EMS inappropriate use should be assessed both cross-sectionally, with episodic inappropriate use, and longitudinally, with EMS FU criterias. Only by investigating both approaches will we be able to analyze the phenomenon as a whole. As for the profiles of service use, it is clear how important this data can be for us to be able to draw up truly specific policies for each profile of use. Finally, it is necessary to promote studies that evaluate the pediatric population, since it represents a significant proportion of consultations in emergency environments around the world. Abbreviations Emergency service - EMS Saúde da População do Pronto Socorro - SPPS Pronto Socorro de Pelotas - PSP Frequent Users - FU Sistema Único de Saúde - SUS Condições Sensíveis à Atenção primária - CSAP Unidade de Pronto Atendimento - UPA Primary Health Care - PHC Confidence interval - CI Manchester Triage Scale - MTS Declarations Ethics approval and consent to participate All methods were carried out in accordance with the Declaration of Helsinki and Regulations by Brazilian National Committee of Ethics in Research. The study was approved by the Institutional Review Board of the FAMED-UFPel in March 2020 (CAAE: 17785219.1.0000.5317). Written consent was obtained from all participants. Consent for publication Not applicable Availability of data and materials RedCap was used to collect the information during the baseline interview. Competing interests None Funding This work was supported by the Rio Grande do Sul Research Foundation (FAPERGS), FAPERGS notice 05/2019 – Programa Pesquisador Gaúcho-PQG (No. 19/2551-0001704-9). Author’s contribution All authors have approved the final article. BPN coordinated and led conception and design, and coordinated data collection, data analysis and manuscript writing. TFDA led data collection and manuscript analysis. AOFMF conducted data anlysis and writing. EBC contributed to data analysis, drafting and revising the manuscript. FMD conducted drafting and revising the manuscript. Acknowledgments Author’s information (optional) References Almeida A, Vales J. The impact of primary health care reform on hospital emergency department overcrowding: Evidence from the Portuguese reform. Int J Health Plann Manage. janeiro de 2020;35(1):368–77. Pines JM, Mullins PM, Cooper JK, Feng LB, Roth KE. 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Supplementary Files 1.png Flowchart 1 - Flowchart of eligible patients for monitoring in SPPS Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5731795","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":399281438,"identity":"59c69e74-af99-4a23-b149-71c3ce810d6f","order_by":0,"name":"Thales Filipe Delmonico Aguiar","email":"data:image/png;base64,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","orcid":"","institution":"Universidade Federal de Pelotas","correspondingAuthor":true,"prefix":"","firstName":"Thales","middleName":"Filipe Delmonico","lastName":"Aguiar","suffix":""},{"id":399281439,"identity":"99630a8d-81df-4e0d-b534-e938e72d66a7","order_by":1,"name":"Antonio Orlando Farias Martins Filho","email":"","orcid":"","institution":"Universidade Federal de Pelotas","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"Orlando Farias Martins","lastName":"Filho","suffix":""},{"id":399281440,"identity":"296b9ce1-e94c-4e69-af26-b2acae43bcf2","order_by":2,"name":"Everton Bruno Castanha","email":"","orcid":"","institution":"Universidade Federal de Pelotas","correspondingAuthor":false,"prefix":"","firstName":"Everton","middleName":"Bruno","lastName":"Castanha","suffix":""},{"id":399281441,"identity":"acf2f29b-b914-4c22-91f5-e7e82fe977dc","order_by":3,"name":"Felipe Mendes Delpino","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Felipe","middleName":"Mendes","lastName":"Delpino","suffix":""},{"id":399281442,"identity":"57c5f55d-5767-4fb4-870e-10deb890bfed","order_by":4,"name":"Bruno Pereira Nunes","email":"","orcid":"","institution":"University of Illinois Urbana-Champaign","correspondingAuthor":false,"prefix":"","firstName":"Bruno","middleName":"Pereira","lastName":"Nunes","suffix":""}],"badges":[],"createdAt":"2024-12-30 00:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5731795/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5731795/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108805087,"identity":"608e0e6d-5d4f-47b4-a83c-bb885d30c35e","added_by":"auto","created_at":"2026-05-08 15:24:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":480954,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5731795/v1/2bf51862-43f8-4dff-b5bb-8c45588313e0.pdf"},{"id":73386140,"identity":"c4434062-76ff-4448-9be5-444358245c0d","added_by":"auto","created_at":"2025-01-09 12:05:17","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":46499,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart 1\u003c/strong\u003e - Flowchart of eligible patients for monitoring in SPPS\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5731795/v1/538271bd6264d49c8e841c7f.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emergency service user profiles: patterns and inappropriate use in a southern Brazilian cohort, 2021-2022","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStudies indicate an annual increase in demand for Emergency Medical Services (EMS) worldwide\u003csup\u003e1,2\u003c/sup\u003e, varying between 3% and 6% in a year\u003csup\u003e3\u003c/sup\u003e. However just a small portion of it requires immediate medical intervention\u003csup\u003e4\u003c/sup\u003e, which represents one of the EMS overcrowding causes. This phenomenon is observed in countries with different socio-economic realities, different health systems and different intensities around the world\u003csup\u003e5\u003c/sup\u003e. That results in serious consequences to health services, like the worsening of the service quality\u003csup\u003e6\u003c/sup\u003e, dissatisfaction with the service on the part of users or workers\u003csup\u003e7\u0026ndash;10\u003c/sup\u003e and may lead to inappropriate support to truly urgent conditions\u003csup\u003e11\u003c/sup\u003e. Another important consequence of EMS overcrowding is the increase of the already high operating cost\u003csup\u003e12\u003c/sup\u003e threatening health system sustainability\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe EMS inappropriate use is also related to a high cost increase in this scenario, because presents an important avoidable cause to overcrowding\u003csup\u003e13\u0026ndash;15\u003c/sup\u003e. There is no consensus on the definition of inappropriate use, some of which conflict with each other\u003csup\u003e16\u003c/sup\u003e. Health professionals tend to consider inappropriate use as something that could be better resolved in other care settings, especially Primary Health Care (PHC)\u003csup\u003e17\u003c/sup\u003e. Another point of view that has been discussed is whether or not to get immediate attention. Consults that could have been postponed for 24 hours, without adding up risk to patients, have been treated like inappropriate\u003csup\u003e4,18\u003c/sup\u003e. Both concepts are linked to fundamental problems: the perception of superiority and resolubility from the EMS above PHC\u003csup\u003e16\u003c/sup\u003e and a mistaken self-perception of the severity of the symptoms presented, leading to a hasty search for a service with a greater diagnostic repertoire and medical interventions\u003csup\u003e15,17,19,20\u003c/sup\u003e. The reported prevalence of inappropriate EMS use ranges from 10.0\u0026ndash;90.0%\u003csup\u003e17,21\u003c/sup\u003e, depending on the criteria established for the evaluation, as there is no consensus on the definition.\u003c/p\u003e \u003cp\u003eWithin this problem, the frequency of EMS use seems to be a fundamental discussion to understand the consequences over the health services and systems. Literature lacks a standardized definition for the cut-off point to analyze this phenomenon, varying between \u0026ge;\u0026thinsp;3 to \u0026ge;\u0026thinsp;20 visits per patient in a year\u003csup\u003e17\u003c/sup\u003e. However, a cut-off point of \u0026ge;\u0026thinsp;4 episodes per year per patient has been widely used to analyze the frequent users (FU) of EMS \u003csup\u003e15\u003c/sup\u003e. The FU have already been associated with a higher risk of hospitalization, of functional decline, of complications during treatment/procedures and higher mortality between ESM patients\u003csup\u003e22\u0026ndash;25\u003c/sup\u003e. Although numerically they represent a small portion of the population that uses EMS, FU have already been associated with a large portion of the total cost of these services\u003csup\u003e26\u0026ndash;28\u003c/sup\u003e, and it may require a cost of 24.0% of the service budget to serve the 1.0% of the most frequent users\u003csup\u003e29\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite Brazil's Urgent and Emergency network being costly to the \u0026ldquo;Sistema \u0026Uacute;nico de Sa\u0026uacute;de\u0026rdquo; (SUS), national healthcare universal system, there were few primary studies realizing the impact of inappropriate use to our services and our health system\u003csup\u003e30\u0026ndash;35\u003c/sup\u003e. In Pelotas, in the extreme south of Brazil, there was a pioneering study in 2004 to investigate the issue of inappropriate use and characteristics of use in a single EMS\u003csup\u003e30,34\u003c/sup\u003e. After 17 years, in 2021, a new cohort study was designed to better understand and measure the impact of this phenomenon on the city's only public EMS\u003csup\u003e36\u003c/sup\u003e, entitled \u0026ldquo;Machine learning analysis to predict health outcomes among emergency department users in Southern Brazil\u0026rdquo; - it\u0026rsquo;s being used \u0026ldquo;Sa\u0026uacute;de da Popula\u0026ccedil;\u0026atilde;o do Pronto Socorro\u0026rdquo; (SPPS) as a short name for this study. Based on these data, this paper evaluated the reuse profile of Pelotas city Emergency Service (PSP) users, in a year, from the frequency of this service use and its intersection with the inappropriate use of EMS by the perspective of a protocol validated in Brazil\u003csup\u003e37\u003c/sup\u003e. This was designed to respond to the hypothesis that there are different patterns of PSP reuse by population, influenced by different variables of personal profile and the regional health system dynamics.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and sample\u003c/h2\u003e \u003cp\u003eThe SPPS is a prospective cohort aiming to evaluate reutilization and associated factors on patients admitted to the PSP in a medium-size city in the southeast Brazil between may 2021 and august 2022. The baseline data collection took place between May and August 2021 through a survey carried out on patients admitted to the PSP by a team of hired researchers, composed of health professionals and undergraduate health students. In 2022, using PSP internal data, the second study step was realized, investigating the service reutilization by first step volunteers between August 2021 and August 2022. Subsequently, a quality control with 10% of the sample was conducted, by phone, evaluating whether the answers from the baseline remained consistent with what the patient would currently answer. Following the removal of losses, refusals, and duplicates, the final sample size was calculated, the final sample was 2909 (Flowchart 1).\u003c/p\u003e \u003cp\u003eThe design study and the sample calculation had been outlined and proposed to take place before the COVID-19 pandemic. As the pandemic was still ongoing during baseline collection in 2021, the number of collected interviews were lower (n\u0026thinsp;=\u0026thinsp;4365) than stipulated (n\u0026thinsp;=\u0026thinsp;4892) to analyze all the proposed outcomes (Flowchart 1).The cause of this lower data collect was probability the change of the PSP dynamic after a municipal flu syndrome emergency service setted up in Pelotas.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFlowchart 1\u003c/b\u003e - Flowchart of eligible patients for monitoring in SPPS\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe inclusion criteria were age\u0026thinsp;\u0026ge;\u0026thinsp;18 years and seeking care at the PSP. The exclusion criteria were age\u0026thinsp;\u0026le;\u0026thinsp;18 years, clinical emergency admission in the emergency room by municipal ambulances or Mobile Emergency Service (SAMU), patients taken for forensic procedures and carriers patients of severe communication deficit condition.\u003c/p\u003e\n\u003ch3\u003eReutilization subgroups\u003c/h3\u003e\n\u003cp\u003eOur analyses were stratified according to EMS reutilization frequency pattern: \u0026ldquo;non-reusers\u0026rdquo;, \u0026ldquo;users\u0026rdquo;, \u0026ldquo;regular users\u0026rdquo; and \u0026ldquo;hyperusers\u0026rdquo;. We considered \u0026ldquo;non-reusers\u0026rdquo; as patients who didn\u0026rsquo;t use the emergency in a year. \u0026ldquo;Users\u0026rdquo; as patients whose pattern of EMS use varied between \u0026ge;\u0026thinsp;1 or \u0026le;\u0026thinsp;3 utilizations in a year. \u0026ldquo;Regular users\u0026rdquo; as patients whose pattern of EMS use varied between \u0026ge;\u0026thinsp;4 or \u0026le;\u0026thinsp;9 utilizations in a year. \u0026ldquo;Hyperusers\u0026rdquo; as patients whose pattern of EMS use was \u0026ge;\u0026thinsp;10 utilizations. This last group was created because, to do the baseline collection, we programmed the RedCap to accept at most 10 utilizations in a year per patient. Therefore, we created a separate subgroup for this pattern, as we cannot determine whether each hyperuser used the service 10 or more times. Notably, the literature defines FU as the sum of the \u0026ldquo;regular users\u0026rdquo; and \u0026ldquo;hyperusers\u0026rdquo; groups.\u003c/p\u003e\n\u003ch3\u003eSociodemographic variables\u003c/h3\u003e\n\u003cp\u003eWe used the following sociodemographic variables: gender, age, skin color and schooling. Participants self-identified their gender as male or female. Age was collected in complete years and categorized into three subgroups: equal 18 or \u0026le;\u0026thinsp;39 years old, \u0026ge; 40 or \u0026le;\u0026thinsp;59 years old and \u0026ge;\u0026thinsp;60 years old. Participants self-identified their skin color as white, black or brown/yellow/indigenous, which were analyzed together. About schooling, the possible answers were: can't read/didn't study, collected separately, but analyzed jointly in this study; incomplete elementary school; complete elementary school or incomplete high school, collected separately, but analyzed jointly in this study; complete high school or incomplete higher education, collected separately, but analyzed jointly in this study; and complete higher education or more degrees, collected separately, but analyzed jointly in this study.\u003c/p\u003e\n\u003ch3\u003eHealth self-perception, severity and symptoms onset\u003c/h3\u003e\n\u003cp\u003ePatients' self-perception of their health was assessed in terms of symptom duration, self-perception of severity and need for immediate treatment, and general self-perception of health. About symptom time onset, patients could choose from the options: less than 1 day, less than 1 week, more than 1 week, less than 1 month and more than 1 month. About self-perception of severity and need for immediate treatment, the patient could answer whether or not they thought they needed care. Patients rated their general health as: \u0026ldquo;very bad\u0026rdquo; or \u0026ldquo;bad\u0026rdquo;, collected separately but analyzed together in this study, \u0026ldquo;fair\u0026rdquo;, and \u0026ldquo;good\u0026rdquo; or \u0026ldquo;excellent\u0026rdquo;, collected separately but analyzed together in this study.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eInappropriate use\u003c/h2\u003e \u003cp\u003eAs episodic criteria for EMS inappropriate use, we used criteria from a Spanish protocol already validated in Brazil\u003csup\u003e37,40\u003c/sup\u003e, and assessed severity criteria, diagnostic intensity criteria, treatment criteria, \u0026ldquo;other criteria\u0026rdquo; and spontaneous consultation criteria. The presence of at least one or the complete absence, \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;, of the following severity criteria were considered: loss of consciousness, disorientation, coma, instability, numbness, sudden loss of vision or hearing, pulse changes (\u0026lt;\u0026thinsp;50 or \u0026gt;\u0026thinsp;140 beats per minute), arrhythmias (\u0026lt;\u0026thinsp;50 or \u0026gt;\u0026thinsp;140 beats per minute), blood pressure changes (systolic\u0026thinsp;\u0026lt;\u0026thinsp;90 or \u0026gt;\u0026thinsp;200 and diastolic\u0026thinsp;\u0026lt;\u0026thinsp;60 or \u0026gt;\u0026thinsp;120), changes in electrolytes or blood gases, active bleeding and loss of functional capacity of any part of the body. As the criteria already present, the presence of at least one or the complete absence of the following diagnostic intensity criteria were considered: constant monitoring of vital signs every 2 hours, radiography of any kind, laboratory tests and electrocardiogram - except for known heart diseases who consult for reasons unrelated to the disease. The presence of at least one or the complete absence of the following treatment criteria were taken into account: administration of medication or intravenous fluid, administration of oxygen, placement of a plaster cast (except bandages). \u0026ldquo;Other criteria\u0026rdquo; included the presence of at least one or the complete absence of: the need for a 12-hour observation stay in the emergency department and hospitalization or transfer to another department. Lastly, we considered the presence of at least one or the complete absence of the following criteria for spontaneous consultation: patient coming from an accident and requiring medical assessment, symptoms that indicate vital urgency (chest pain, chest tightness and acute abdominal pain), previous health condition that usually requires hospitalization, doctor's advice that the patient go to the emergency room because of these symptoms, need for urgent medical care and the EMS is the closest place, and other spontaneous consultation criteria determined by the doctor who attended the patient.\u003c/p\u003e \u003cp\u003eTo the search for care in EMS to be considered as an inappropriate use of the service, the patient couldn\u0026rsquo;t present \u0026ldquo;positive\u0026rdquo; for any of the five criteria described above. Finally, the color of the triage bracelet was recorded based on the adapted Manchester Triage Scale (MTS), which is used by the service. The blue and green bracelets are for patients who are not serious enough to require immediate care; yellow for those with some dysfunction, but not life-threatening in the short term; and red, which indicates dysfunction requiring immediate care due to the risk to life.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePelotas and the Municipal Emergency Service\u003c/h3\u003e\n\u003cp\u003eAccording to the 2022 Annual Management Report of the Municipal Health Department of Pelotas - Rio Grande do Sul, Pelotas is a city of less than 350,000 inhabitants. Data from 2021 from the Brazilian Institute of Geography and Statistics showed that the city ranked 413th in terms of Gross Domestic Product per capita out of 497 municipalities in RS, making it one of the cities with the poorest population in the state. In healthcare terms, the city serves as a reference for approximately 1\u0026nbsp;million people across the 3rd and 7th Regional Health Coordination areas\u003csup\u003e38\u003c/sup\u003e. The Pelotas Emergency Room (\u0026ldquo;PSP\u0026rdquo;, in Portuguese), the city's sole public hospital emergency department, received 47,784 and 65,056 visits respectively in 2021 and 2022.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed through the Stata statistical software version 15.0 (Statacorp., College Station, TX, USA). An initial descriptive analysis of the reuse data was conducted to characterize the sample. Categorical variables were reported as relative frequencies, using a confidence interval (CI) by 95%. The chi-squared test was applied to assess differences between categorical variables. A 5% significance level was established for all statistical analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e All methods were carried out in accordance with the Declaration of Helsinki and Regulations by Brazilian National Committee of Ethics in Research. The study was approved by the Institutional Review Board of the Federal University of Pelotas' Faculty of Medicine (FAMED-UFPel) in March 2020 (CAAE: 17785219.1.0000.5317). Study protocol details are published elsewhere\u003csup\u003e36\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIt was realized the evaluation of the sample reuse (n\u0026thinsp;=\u0026thinsp;2909) one year after the baseline. There was reused by 61.0% (n\u0026thinsp;=\u0026thinsp;1776) of participants\u003csup\u003e39\u003c/sup\u003e, as previously published, accounting for 4935 searches for medical care in the PSP (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The \u0026ldquo;non-reusers\u0026rdquo; of service in a year were 1133 study participants. The \u0026ldquo;users\u0026rdquo; subgroup of the service accounted for 74.4% (72.4\u0026ndash;76.4%, CI 95%) of reusers and 42.7% of use (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding \u0026ldquo;regular users\u0026rdquo;, this subgroup represents 21.6% (19.8\u0026ndash;23.6%, CI 95%) of the sample, corresponding to 43.2% of total service utilization (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). \u0026ldquo;Hyperusers\u0026rdquo;, chronic users of service, accounted for 3.9% (3.1-5.0%, CI 95%) of reusers and at least 14,2% of total utilization (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Then, we were able to calculate that frequent use was 25.5% of the sample, accounting for 57.4% of the PSP uses recorded.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePercentage of PSP reusers and PSP reutilization by each reutilization pattern subgroup.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReutilization in\u003c/p\u003e\n \u003cp\u003ea year\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage of reusers\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1776)\u003c/p\u003e\n \u003cp\u003e%, 95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage of total use\u003c/p\u003e\n \u003cp\u003eAnalyzed visits\u0026thinsp;=\u0026thinsp;4935\u003c/p\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.9 (39.7\u0026ndash;44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.9 (19.1\u0026ndash;22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.6 (10.2\u0026ndash;13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.5 (6.4\u0026ndash;8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.0 (4.0\u0026ndash;6;1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.1 (2.4-4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.9 (2.2\u0026ndash;3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.0 (1.4\u0026ndash;2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.1 (0.7\u0026ndash;1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.9 (3.1-5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eRegarding sociodemographic stratification, we found a tendency of higher prevalence of FU among women, representing 58.8% (53.8\u0026ndash;63.7%, CI 95%) of \u0026ldquo;regular users\u0026rdquo; and 62.9% (50.9\u0026ndash;73.3%, CI 95%) of \u0026ldquo;hyperusers\u0026rdquo; (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). \u0026ldquo;Non-users\u0026rdquo; were more often males, approximately 55.0% (52.1\u0026ndash;57.9%, CI 95%), and there was no difference between the genders among \u0026ldquo;users\u0026rdquo;. Regarding age, at appropriate use groups, despite the fact that there was a tendency to older patients, \u0026ldquo;60 years or more\u0026rdquo;, have a higher prevalence, just \u0026ldquo;users\u0026rdquo; presented significant statistical differences (40.7%; 38.1\u0026ndash;43.4%, CI 95%). Among \u0026ldquo;hyperusers\u0026rdquo;, on the other hand, there was a high prevalence of use in the \u0026ldquo;18 to 39 years\u0026rdquo; group, representing 55.7% (43.9\u0026ndash;66.9%, CI 95%). Between \u0026quot;hyperusers\u0026quot;, patients aged \u0026quot;18 to 39 years\u0026quot; presented a higher prevalence than the general presented in the study sample, 32,2%, as already published\u003csup\u003e39\u003c/sup\u003e. Regarding skin color, white was the most prevalent skin color across all, being numerically higher among \u0026ldquo;non-users\u0026rdquo; (78.3%) and lower among \u0026ldquo;hyperusers\u0026rdquo; (67.1%). Among \u0026ldquo;hyperusers\u0026rdquo;, the lower prevalence of use among white-skinned interviewees occurred at the expense of a greater increase in this pattern of use among \u0026ldquo;brown/yellow/indigenous\u0026rdquo; (14.3%; 7.8\u0026ndash;24.6%, CI 95%), however, there wasn\u0026rsquo;t statistical significance in the confidence intervals. Between \u0026quot;users\u0026quot;, patients who self-reported as \u0026ldquo;black\u0026rdquo; presented a higher prevalence than the general presented in the study sample, 15.6%, as already published\u003csup\u003e39\u003c/sup\u003e. No significant differences (p\u0026thinsp;=\u0026thinsp;0.993) in educational level were observed to use pattern, with the most of the sample presenting \u0026ldquo;Incomplete elementary school\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" width=\"594\" height=\"474\"\u003e\u003c/p\u003e\n\u003cp\u003eCI: Confidence Interval; ES: Elementary School; HS: High School; HE: Higher Education\u003c/p\u003e\n\u003cp\u003eAbout using profile stratification related to self-rated health, it was observed that across groups the symptoms that led to the use of the service had arisen less than a day (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). In contrast, \u0026ldquo;non-users\u0026rdquo; and \u0026ldquo;users\u0026rdquo; showed a numerically higher prevalence (48.5% and 43.5%, respectively) than the FU group, in which no statistical significance was observed (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). With regard to self-assessed health severity at this care-seeking episode, all utilization profiles showed a prevalence more than 92.3% among patients self-perceiving their condition as serious and in need of immediate care (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). A curious fact was that 100.0% of \u0026ldquo;hyperusers\u0026rdquo; reported needing immediate care and treatment (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Finally, with regard to self-rated health in general, 47.9% of \u0026ldquo;non-users\u0026rdquo; considered their health to be \u0026ldquo;good/ excellent\u0026rdquo;, presenting statistical significance (44.9\u0026ndash;50.9%, IC 95%) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Although \u0026ldquo;hyperusers\u0026rdquo; tended to consider their health as \u0026ldquo;very bad/bad\u0026rdquo; (37.5%), there wasn\u0026rsquo;t statistical significance (26.5\u0026ndash;50.0%, IC 95%) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eEMS use patterns stratification and self perception of health\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNon-reusers\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUsers\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRegular Users\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHyperusers\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSymptom time onset\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2761\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 1 day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.5 (45.5\u0026ndash;51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e43.5 (40.8\u0026ndash;46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.7 (30.0-39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.7 (27.1\u0026ndash;39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 1 week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.0 (23.5\u0026ndash;28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e28.4 (26.0\u0026ndash;31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.2 (27.6\u0026ndash;37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.2 (25.7\u0026ndash;48.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 1 week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.4 (9.6\u0026ndash;13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e11.7 (10.0-13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.9 (8.1\u0026ndash;14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4 (1.4\u0026ndash;12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than 1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.6 (2.6\u0026ndash;4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3.7 (2.8\u0026ndash;4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.8 (3.7\u0026ndash;8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.9 (0.1\u0026ndash;11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.5 (8.8\u0026ndash;12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e12.7 (11.0-14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.4 (12.9\u0026ndash;20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.8 (11.2\u0026ndash;29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeverity self-perception and need for immediate treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2830\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e92.3 (90.5\u0026ndash;93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.9(93.5\u0026ndash;96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.8 (94.4\u0026ndash;98.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7.7 (6.3\u0026ndash;9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1 (4.0-6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2 (1.8\u0026ndash;5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth self-perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1066\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2697\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGood/excellent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e47.9 (44.9\u0026ndash;50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.0 (37.0-42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.0 (25.4\u0026ndash;35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.2 (9.7\u0026ndash;28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e37.7 (34.8\u0026ndash;40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5 (38.7\u0026ndash;44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.0 (42.0-52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.3 (33.5\u0026ndash;57.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVery bad/bad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14.4 (12.4\u0026ndash;16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.5 (16.4\u0026ndash;20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.0 (18.8\u0026ndash;27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5 (26.5\u0026ndash;50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eCI: Confidence Interval\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eRegarding use profile stratification related to severity criteria, there was a total prevalence of inappropriate use among the studied population of 20.6% (n\u0026thinsp;=\u0026thinsp;2543). However, there wasn\u0026apos;t a statistically significant difference between the use profiles (P\u0026thinsp;=\u0026thinsp;0,300) (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). In terms of the MTS, all groups had a high prevalence of \u0026ldquo;yellow\u0026rdquo; screening, ranging from 84.9% for \u0026ldquo;non-users\u0026rdquo; to 89.5% for \u0026ldquo;regular users\u0026rdquo;. \u0026ldquo;Non-reusers\u0026rdquo; had the highest prevalence of \u0026ldquo;red\u0026rdquo; (8.7%; 7.2\u0026ndash;10.6%, CI 95%).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u0026ndash; EMS use patterns stratification, criteria for appropriate use and triage based on adapted MTS.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNon-reusers\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUsers\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRegular users\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHyperusers\u003c/p\u003e\n \u003cp\u003e% 95%CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003cp\u003eSample\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeverity criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.004\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2545\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.2 (31.3\u0026ndash;37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.9 (26.4\u0026ndash;31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.8 (22.4\u0026ndash;31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.4 (30.4\u0026ndash;55.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65.8 (62.9\u0026ndash;68.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.1 (68.3\u0026ndash;73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.2 (68.2\u0026ndash;77.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.6 (44.7\u0026ndash;69.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiagnostic and intensity criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;968\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.180\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2379\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.4 (54.3\u0026ndash;60.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.9 (52.8\u0026ndash;58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.6 (48.9\u0026ndash;60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.6 (56.3\u0026ndash;80.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.6 (39.5\u0026ndash;45.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.1 (41.2\u0026ndash;47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.4 (40.0\u0026ndash;51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.4 (19.7\u0026ndash;43.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTreatment criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;965\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;306\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.016\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2372\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.3 (50.1\u0026ndash;56.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7 (43.7\u0026ndash;49.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.4 (40.9\u0026ndash;52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.6 (40.4\u0026ndash;66.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.7 (43.6\u0026ndash;49.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.3 (50.3\u0026ndash;56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.6 (48.0-59.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.4 (33.8\u0026ndash;59.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;965\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.038\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2380\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.1 (24.4\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.1 (26.5\u0026ndash;32.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.1 (25.2\u0026ndash;35.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.6 (32.1\u0026ndash;15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.9 (69.9\u0026ndash;76.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.9 (68.0-73.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.9 (64.5\u0026ndash;74.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.4 (42.1\u0026ndash;67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpontaneous consultation criteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1087\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.426\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2442\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.8 (43.7\u0026ndash;49.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.2 (41.3\u0026ndash;47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.6 (40.3\u0026ndash;51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.4 (40.5\u0026ndash;65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.2 (50.0-56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.8 (52.8\u0026ndash;58.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.4 (49.0-59.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.6 (34.1\u0026ndash;59.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInappropriate use of EMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;343\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.300\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2543\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.2 (77.7\u0026ndash;82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77.8 (75.2\u0026ndash;82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e80.8 (76.2\u0026ndash;84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.8 (73.0\u0026ndash;92.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.8 (17.4\u0026ndash;22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.2 (19.9\u0026ndash;24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.2 (15.4\u0026ndash;23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.2 (8.0-26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdapted MTS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;371\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026thinsp;=\u0026thinsp;0.003\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2789\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.5 (1.7\u0026ndash;3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7 (1.1\u0026ndash;2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8 (0.3\u0026ndash;2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4 (0.2\u0026ndash;9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGreen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.8 (2.8\u0026ndash;5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.7 (4.5\u0026ndash;7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.9 (3.9\u0026ndash;8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.6 (3.9\u0026ndash;17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYellow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.9 (82.7\u0026ndash;87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.8 (83.7\u0026ndash;87.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.5 (85.9 92.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.6 (78.7\u0026ndash;94.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.7 (7.2\u0026ndash;10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8 (5.6\u0026ndash;84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.8 (2.3\u0026ndash;6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.4 (0.2\u0026ndash;9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eCI: Confidence Interval\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective cohort study evaluated PSP EMS reuse over one year and its potential determinants. We found that FU, \"regular users\" and \"hyperusers\", comprising 25.5% of the sample, accounted for 57.4% of all recorded EMS uses. Inappropriate use was identified in 20.6% of the sample, with no significant differences in reuse patterns between groups. The MTS categorization indicated overestimation of severity according to PAHU criteria. Perceiving symptoms as severe and requiring immediate treatment appeared to influence inappropriate use. These and other research findings will be discussed in the following subsections.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEMS reuse and reuse patterns\u003c/h2\u003e \u003cp\u003eThree Brazilian primary studies evaluated the prevalence of EMS reuse\u003csup\u003e30,32,34,35\u003c/sup\u003e. One of them was a cross-sectional study conducted in Pelotas in 2004, also in PSP\u003csup\u003e30,34\u003c/sup\u003e, which found a self-reported FU of 20.0%. In addition, it pointed out that 5.9% of the sample self-reported using the EMS in three or more episodes in the last three months. The study did not show the total prevalence of reuse in the service. Another Brazilian cohort, conducted in Ouro Preto, Minas Gerais, in 2012\u003csup\u003e32\u003c/sup\u003e, evaluated an Emergency Care Unit (\u0026ldquo;UPA\u0026rdquo;, in Portuguese) through medical records during a year. It pointed out to a FU prevalence by 16.4% of the sample and described that more than a half of the patients reused the service in a year. The study did not show the total prevalence of reuse in the service. Finally, the third study\u003csup\u003e35\u003c/sup\u003e was conducted at a single EMS in Vit\u0026oacute;ria, Esp\u0026iacute;rito Santo, during December 2019, targeting individuals aged between 18 to 39 years old. This study showed a self-reported reuse of 85.1% and frequent use of 49.3% in the sample.\u003c/p\u003e \u003cp\u003eComparing the findings from SPPS to CARRET et al.\u003csup\u003e30,34\u003c/sup\u003e, a significant difference in FU prevalence was observed between the studies. Even though more emergency services have been created in Pelotas over the past 17 years and the SPPS is no longer the only public emergency in the city, the higher prevalence found by us suggests two possible interpretations: either there has been a worsening in access to PHC or self-reported reuse was influenced by memory bias. The Ouro Preto study\u003csup\u003e32\u003c/sup\u003e, conducted in a UPA, on the other hand, showed a FU prevalence approximately 35.0% lower than that recorded in the SPPS. A possible explanation lies in differing factors influencing inappropriate emergency use in different care settings.\u003c/p\u003e \u003cp\u003eAbout studies from other countries, a 2021 Italian multicenter study\u003csup\u003e41\u003c/sup\u003e, also conducted during the cooling-off period of COVID-2019 pandemic, presented a total EMS reutilization of 22,8% of the sample. Applying the same criteria for FU as our study, revealed a FU prevalence of 2,9% of the sample, with these patients accounting for 11,9% of all uses. A EMS Portuguese single-center cohort\u003csup\u003e42\u003c/sup\u003e rated by similar criteria, \u0026ldquo;regular users\u0026rdquo; as those with between 4 and 10 uses in a year and \u0026ldquo;hyperusers\u0026rdquo; as those with 10 or more utilizations in a year. \u0026ldquo;Regular users\u0026rdquo; represented 5.3% of the sample, accounting for 17.5% of health consultations, while \u0026ldquo;hyperusers\u0026rdquo; represented 0.3% of the sample and accounted for 3.0% of medical consultations.\u003c/p\u003e \u003cp\u003eWe can see how significant the data we found on the Pelotas service in 2021 was. Despite the underestimation of actual reuse in the service, there were approximately 8.8 times more FU and 4.8 times more uses by FU than in the Italian study\u003csup\u003e41\u003c/sup\u003e. Regarding \u0026ldquo;hyperusers\u0026rdquo; and \u0026ldquo;regular users\u0026rdquo; in the Portuguese study\u003csup\u003e42\u003c/sup\u003e, although the criteria were slightly different, we found a prevalence 13 times higher for \u0026ldquo;hyperusers\u0026rdquo; and they were proportionally responsible for 4.9 more emergency visits. Comparing \u0026ldquo;regular users\u0026rdquo;, we found 4.3 times more patients using this pattern in EMS, accounting for 2.4 more consultations.\u003c/p\u003e \u003cp\u003eA 2006 North American study\u003csup\u003e43\u003c/sup\u003e showed that 63.0% of the sample reused EMS, and 8.0% of frequent users were related to 28.0% of medical care. These findings were very similar to those evaluated by the SPPS, with a prevalence of reuse of 61.0%\u003csup\u003e39\u003c/sup\u003e and with the 7.0% of frequent users representing 22.8% of users. Notably, the North American health system contributes to inappropriate service use, as uninsured individuals seek care in these settings\u003csup\u003e43\u003c/sup\u003e. This should not happen in a universal and public health system such as the SUS.\u003c/p\u003e \u003cp\u003eSome studies suggest that just PHC access may not be enough to control chronic diseases in patients who frequently use emergency services, as the follow-up rate in PHC is lower than necessary for these patients\u003csup\u003e44,45\u003c/sup\u003e. EMS FU also frequently uses non-emergency health services\u003csup\u003e46,47\u003c/sup\u003e. Despite PHC access, non-life-threatening acute illnesses are often bypassed in favor of direct emergency room consultation, due to greater trust in this environment, which may be the key to inappropriate use\u003csup\u003e3\u003c/sup\u003e. This relationship was corroborated by a study\u003csup\u003e49\u003c/sup\u003e showing inappropriate use linked to trust in hospital services and distrust in PHC quality, reaching 65.1% of inappropriate use for this reason in the sample.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEMS reuse pattern and sociodemographic criteria\u003c/h2\u003e \u003cp\u003eThe SPPS identified a tendency toward FU among women and \u0026ldquo;hyperuse\u0026rdquo; among young adults, \u0026ldquo;18 to 39 years\u0026rdquo;. To the best of our knowledge no Brazilian study focused on sociodemographic criteria and EMS use patterns. The Piracicaba primary study\u003csup\u003e31\u003c/sup\u003e, conducted in two of four city\u0026rsquo;s UPA\u0026rsquo;, found a 2,6 major rate by 60 or more years of population to be screened like \u0026ldquo;blue\u0026rdquo;, categorized as non-urgent. On the other hand, the Guarapuava study\u003csup\u003e33\u003c/sup\u003e, conducted in two city's UPAs, identified a strong link between EMS misuse and pediatric patients (0\u0026ndash;17 years). Finally, in the Vit\u0026oacute;ria study\u003csup\u003e35\u003c/sup\u003e, there wasn't a statistically significant difference between gender and inappropriate use, educational level and inappropriate use or skin color and inappropriate use.\u003c/p\u003e \u003cp\u003eFURIA et al.\u003csup\u003e41\u003c/sup\u003e showed a tendency for FU to be more prevalent among women (53.9%), as corroborated by the literature\u003csup\u003e43\u003c/sup\u003e and observed in SPPS. Furthermore, in the Italian study, in terms of age, male FUs tended to be older (56.5 years old on average) than non-FUs (52.3 years old on average); no difference existed between female FUs and non-FUs (56.2%). Similarly, Portugal\u003csup\u003e42\u003c/sup\u003e reported higher inappropriate use among women. No prior studies examined age and self-reported skin color's impact, as we did.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEMS reuse pattern and health self-perception\u003c/h2\u003e \u003cp\u003eTwo out of five Brazilian studies assessed patients' health self-perception. However, none examined reuse from this perspective. As for the start of symptoms, the study by SOUZA.\u003csup\u003e31\u003c/sup\u003e found that 65.2% of patients started having the symptoms that brought them to the EMS less than three days ago. CARRET et al.\u003csup\u003e34\u003c/sup\u003e, in contrast, found that 40.7% of patients sought EMS care on the same day of symptom onset, while 12.0% waited more than 10 days after symptom onset. Regarding health self-perception, CARRET et al.\u003csup\u003e30\u003c/sup\u003e reported that 46.5% rated their health as 'bad' and that, in this current episode, 70% considered needing emergency care. SOUZA et al.\u003csup\u003e31\u003c/sup\u003e, however, pointed out that in her study 59.0% of the patients considered their health to be \u0026ldquo;satisfactory\u0026rdquo;, with 71.4% requiring care during this episode.\u003c/p\u003e \u003cp\u003eCARRET et al.\u003csup\u003e34\u003c/sup\u003e indicated that self-perceived health was a poor predictor of the need for emergency care, with low specificity (37.0%). SOUZA et al.\u003csup\u003e31\u003c/sup\u003e concurred showing a 9,8 greater chance of patients with a self-perception of emergency being screened as \u0026ldquo;blue\u0026rdquo;, the non-emergency bracelet. The literature has already demonstrated that self-perceived severity of the condition is directly associated with emergency service utilization\u003csup\u003e3,50\u003c/sup\u003e. Anxiety in the face of symptoms seems to be a key point in unraveling the episodic inappropriate use of EMS\u003csup\u003e3,48\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSPPS findings may elucidate the relationship between FU or appropriate use and symptoms onset. The symptom onset was typically \u0026ldquo;less than one day\u0026rdquo; across appropriate use patterns, but there was no statistical significance between FU patterns. This may indicate the tendency for appropriate use patterns to be, in fact, related to acute symptoms, while FU patterns seek care in EMS in an eradicative way, including for chronic symptoms that are better managed by PHC. About Self-perception of severity and need for immediate treatment, more than 92,3% of the SPPS sample considered that his condition was severe and required immediate treatment in all groups, which is in line with what is debated about anxiety, the difficulty of critically self-assessing the real severity of symptoms and the ability to self-refer to the correct health environment within the country's health system. Furthermore, deteriorating self-perceived health was linked to EMS hyperutilization. Finally, about general self-perception of health,\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eEMS reuse pattern and inappropriate EMS use\u003c/h2\u003e \u003cp\u003eThe SPPS found that inappropriate use was identified in 20.6% of the sample, with no significant differences in reuse patterns between groups. The MTS revealed over 90% compatibility with emergency environments criterias, being categorized as \u0026ldquo;yellow\u0026rdquo; or \u0026ldquo;red\u0026rdquo;. However, the screenings as \"blue\" and \"green\" combined, in all groups, varied between 6.3 and 10.0%, indicating overestimation of severity according to PAHU criteria.\u003c/p\u003e \u003cp\u003eThe other five Brazilian studies assessed the EMS misuse using the PAHU protocol\u003csup\u003e40\u003c/sup\u003e or its derivatives\u003csup\u003e31,32\u003c/sup\u003e, but none of them associated the inappropriate use with reuse patterns. The studies from Pelotas\u003csup\u003e34\u003c/sup\u003e and from Vit\u0026oacute;ria\u003csup\u003e35\u003c/sup\u003e found, respectively, a prevalence of 24.2% and 30,6% of municipal hospital emergency users who didn\u0026rsquo;t meet any of the criteria for adequate EMS use, constituting inadequate use. The other three studies were carried out in UPAs and found an inadequate use of more than 45% in one of them based on different criteria: adapted PAHU\u003csup\u003e32\u003c/sup\u003e, indicators of inappropriate use found in a systematic review\u003csup\u003e33\u003c/sup\u003e and \"blue\" screening\u003csup\u003e31\u003c/sup\u003e. These findings made us question whether the criteria for inappropriate use of EMS should be the same for different health care contexts, such as UPA and hospital emergency.\u003c/p\u003e \u003cp\u003eIn the Italian study\u003csup\u003e41\u003c/sup\u003e, logistic regression showed an inversely proportional relationship between appropriate use and FU, with UF being three times more likely to be classified as non-urgent than non-FU. In this sample 76.2% of FU and 73.0% of non-FU were classified as inappropriate use. The criteria used in this study for appropriateness were indication for hospitalization and death. The classification in triage by the nursing team was also taken into account, with FU patients classified with blue presenting three times more classified as non-urgent use than non-FU patients. Another study, conducted in the United States\u003csup\u003e51\u003c/sup\u003e, found a prevalence of 3.3% of inappropriate use, based on the criterion that misuse is when complementary diagnostic tests, procedures or treatments were unnecessary. These were mainly related to psychiatric disorders and dental conditions.\u003c/p\u003e \u003cp\u003eA French cross-sectional study\u003csup\u003e20,68\u003c/sup\u003e found 2.0% of non-urgent patients willing to be redirected to PHC. 23.5% However, wanted to be guaranteed an appointment and requested that this unit be close to a hospital and 17.6% would like the emergency doctor to agree with this. The location of primary care, the journey to it, guaranteed access, and confirmation that these symptoms are not life-threatening are relevant factors influencing population choices between PHC and EMS.\u003c/p\u003e \u003cp\u003ePrimary Care Sensitive Conditions (\u0026ldquo;CSAP\u0026rdquo;, in Portuguese) serve as indicators in Brazilian hospital care, which points to clinical conditions that could have been managed in PHC, except in cases of exacerbation of the chronic condition\u003csup\u003e52\u003c/sup\u003e, linked to EMS misuse in Brazil\u003csup\u003e33\u003c/sup\u003e. Other international studies support that inappropriate use stems from demanding care better suited to PHC or specialty clinics\u003csup\u003e17,53\u0026ndash;55\u003c/sup\u003e. Enhancing PHC with imaging technologies appears promising, it can become even more resolutive to increase resolution from a medical perspective. A Romanian study found 27.9% of non-urgent visits could be managed in PHC if there had been access to electrocardiogram and point-of-care ultrasonography\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA systematic review\u003csup\u003e17\u003c/sup\u003e found that patients who spontaneously sought emergency services were 30.0% more likely to have inadequate use of the service\u003csup\u003e17\u003c/sup\u003e. Regarding triage, a study conducted during the COVID-19 pandemic indicated that patients with \u0026ldquo;green\u0026rdquo; triage were 4 times more likely to have inappropriate use when compared to those triaged as \u0026ldquo;yellow\u0026rdquo;\u003csup\u003e49\u003c/sup\u003e. This study also identified a significant inclination towards misuse among young individuals, with no gender-related association. According to the Pelotas Health Department\u003csup\u003e38\u003c/sup\u003e, 23.0% of consultations at the PSP were considered \u0026ldquo;green\u0026rdquo; or \u0026rdquo;blue\u0026rdquo;, proportionally much lower than that found in our study. One possibility for this may have been the exclusion criteria for pediatric patients, who are more related to the use of emergencies for conditions that are sensitive to primary care\u003csup\u003e33\u003c/sup\u003e, justifying their classification with a lower degree of emergency by triage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic has resulted in a global decline in EMS demand, with demand decreasing by up to 50% in certain countries\u003csup\u003e56\u0026ndash;58\u003c/sup\u003e. In Pelotas, data from the Pelotas Health Department\u003csup\u003e38\u003c/sup\u003e pointed to a process of normalization of PSP care, showing consistent demand growth between 2021 and 2022, after the closure of specialized care for flu-like syndromes\u003csup\u003e38\u003c/sup\u003e, causing patients to return to PSP usage. Even though the Covid-19 pandemic has led to a lower \u0026ldquo;n\u0026rdquo; than expected for the baseline, due to the magnitude of the phenomenon of inappropriate use within the PSP, we consider our data as representative of the service.\u003c/p\u003e \u003cp\u003eIn addition, a possible bias for our study was that patients admitted by ambulance and SAMU were not allowed to participate in our survey, as they were automatically screened with a red bracelet. However, they were eligible for the study if, after stabilizing, they remained under clinical observation in the emergency room. We believe that, although the exclusion of red cards may be a bias, its effect may not have been relevant due to the possibility of these patients' inclusion after clinical stabilization. Finally, in order to fully understand the phenomenon in the city, we need to evaluate other emergency care settings, such as UPA and private EMS.\u003c/p\u003e \u003cp\u003eWe must reiterate that the method used to record the group of \u0026ldquo;hyperusers\u0026rdquo;, as explained in the study's methodology, leads us to underestimate the impact of this population on the results presented in this study. Despite this limitation, as explained in the discussion, when we compare the results of our analysis with the data found in the literature, there is a magnitude of frequent use and inappropriate use that is consistent with what has already been discussed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEMS inappropriate use should be assessed both cross-sectionally, with episodic inappropriate use, and longitudinally, with EMS FU criterias. Only by investigating both approaches will we be able to analyze the phenomenon as a whole. As for the profiles of service use, it is clear how important this data can be for us to be able to draw up truly specific policies for each profile of use. Finally, it is necessary to promote studies that evaluate the pediatric population, since it represents a significant proportion of consultations in emergency environments around the world.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEmergency service - EMS\u003c/p\u003e\n\u003cp\u003eSa\u0026uacute;de da Popula\u0026ccedil;\u0026atilde;o do Pronto Socorro - SPPS\u003c/p\u003e\n\u003cp\u003ePronto Socorro de Pelotas - PSP\u003c/p\u003e\n\u003cp\u003eFrequent Users - FU\u003c/p\u003e\n\u003cp\u003eSistema \u0026Uacute;nico de Sa\u0026uacute;de - SUS\u003c/p\u003e\n\u003cp\u003eCondi\u0026ccedil;\u0026otilde;es Sens\u0026iacute;veis \u0026agrave; Aten\u0026ccedil;\u0026atilde;o prim\u0026aacute;ria - CSAP\u003c/p\u003e\n\u003cp\u003eUnidade de Pronto Atendimento - UPA\u003c/p\u003e\n\u003cp\u003ePrimary Health Care - PHC\u003c/p\u003e\n\u003cp\u003eConfidence interval - CI\u003c/p\u003e\n\u003cp\u003eManchester Triage Scale - MTS\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with the Declaration of Helsinki and Regulations by Brazilian National Committee of Ethics in Research. The study was approved by the Institutional Review Board of the FAMED-UFPel in March 2020 (CAAE: 17785219.1.0000.5317). Written consent was obtained from all participants.\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\u003eRedCap was used to collect the information during the baseline interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Rio Grande do Sul Research Foundation (FAPERGS), FAPERGS notice 05/2019 – Programa Pesquisador Gaúcho-PQG (No. 19/2551-0001704-9).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have approved the final article. BPN coordinated and led conception and design, and coordinated data collection, data analysis and manuscript writing. TFDA led data collection and manuscript analysis. AOFMF conducted data anlysis and writing. EBC contributed to data analysis, drafting and revising the manuscript. FMD conducted drafting and revising the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s information (optional)\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlmeida A, Vales J. The impact of primary health care reform on hospital emergency department overcrowding: Evidence from the Portuguese reform. Int J Health Plann Manage. janeiro de 2020;35(1):368\u0026ndash;77.\u003c/li\u003e\n\u003cli\u003ePines JM, Mullins PM, Cooper JK, Feng LB, Roth KE. 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Adverse events in patients with return emergency department visits. BMJ quality \u0026amp; safety [Internet]. fevereiro de 2015 [citado 14 de outubro de 2024];24(2). Dispon\u0026iacute;vel em: https://pubmed.ncbi.nlm.nih.gov/25540424\u003c/li\u003e\n\u003cli\u003eFuda KK, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med. julho de 2006;48(1):9\u0026ndash;16\u003c/li\u003e\n\u003cli\u003eSalazar A, Bard\u0026eacute;s I, Juan A, Olona N, Sabido M, Corbella X. High mortality rates from medical problems of frequent emergency department users at a university hospital tertiary care centre. Eur J Emerg Med. fevereiro de 2005;12(1):2\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eMaruster L, van der Zee DJ, Buskens E. Identifying Frequent Health Care Users and Care Consumption Patterns: Process Mining of Emergency Medical Services Data. 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Healthcare (Basel). 6 de abril de 2024;12(7):794\u003c/li\u003e\n\u003cli\u003eColineaux H, Le Querrec F, Pourcel L, Gallart JC, Az\u0026eacute;ma O, Lang T, et al. Is the use of emergency departments socially patterned? Int J Public Health. abril de 2018;63(3):397\u0026ndash;407.\u003c/li\u003e\n\u003cli\u003eWestgard BC, Morgan MW, Vazquez-Benitez G, Erickson LO, Zwank MD. An Analysis of Changes in Emergency Department Visits After a State Declaration During the Time of COVID-19. Ann Emerg Med. novembro de 2020;76(5):595\u0026ndash;601.\u003c/li\u003e\n\u003cli\u003eThe effect of national lockdown due to COVID-19 on emergency department visits - PubMed [Internet]. [citado 14 de outubro de 2024]. Dispon\u0026iacute;vel em: https://pubmed.ncbi.nlm.nih.gov/33276799/\u003c/li\u003e\n\u003cli\u003eA S, W B, F G, M K, D W, B E, et al. Medical Emergencies During the COVID-19 Pandemic. Deutsches Arzteblatt international [Internet]. 17 de agosto de 2020 [citado 14 de outubro de 2024];117(33\u0026ndash;34). Dispon\u0026iacute;vel em: https://pubmed.ncbi.nlm.nih.gov/32865489/\u003c/li\u003e\n\u003cli\u003eKurt BF, G\u0026uuml;ven O, Sel\u0026ccedil;uk H. The Effect of the COVID-19 Pandemic on Emergency Department (ED) Admissions in the Only Hospital of City Center ED. Cureus. setembro de 2023;15(9):e44527.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Flowchart 1","content":"\u003cp\u003eFlowchart 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Frequent users, Inappropriate use, Use patterns, Emergency Service, Emergency Service Misuse","lastPublishedDoi":"10.21203/rs.3.rs-5731795/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5731795/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEmergency Medical Services (EMS) overcrowding is a worldwide challenge still in progression. Inappropriate use and reuse play an important role in this phenomenon. However the literature on the patterns of reuse and how personal an regional health system characteristics influence it is still scarce. Therefore, this study aimed to investigate reuse patterns and its determinants.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective cohort study investigate EMS overuse and inappropriate use in Pelotas city, Brazil (2021\u0026ndash;2022). 2909 patients were followed for one year.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e61% of patients reused the service, with 25.5% classified as frequent users (FU), accounting for 57.4% of total visits. Hyperusers (\u0026ge;\u0026thinsp;10 visits/year) represented 3.9% of patients, but 14.2% of total visits. FU were more prevalent among women, while \u0026ldquo;hyperusers\u0026rdquo; were associated with young adults, \u0026ldquo;18 to 49 years\u0026rdquo;. In analyzing the appropriate use criterias, a total of 20.6% of visits were classified as inappropriate, though no significant difference existed across use patterns.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results suggest the need for new studies, looking for population patterns in the profiles of emergency service users, based on frequency of use. From this, it will be possible to base public policies that interfere with the phenomenon.\u003c/p\u003e","manuscriptTitle":"Emergency service user profiles: patterns and inappropriate use in a southern Brazilian cohort, 2021-2022","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-09 12:05:13","doi":"10.21203/rs.3.rs-5731795/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9288407d-3a9b-4702-afee-69a68a34073a","owner":[],"postedDate":"January 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T11:42:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-09 12:05:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5731795","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5731795","identity":"rs-5731795","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}