Abstract

The increase in the demand for Emergency Services is a worldwide phenomenon, and its inappropriate use is one of the main problems. Factors related to the inappropriate use must be investigated to guide improvement in the quality of services. This article aims at analyzing factors associated with the inappropriate use of emergency services. This is a cross-sectional study with secondary data from 384 medical records from two emergency services in a city in central-southern region of the state of Paraná, Brazil, in 2013. A descriptive, bivariate using Pearson’s chi-squared test was performed to verify associations between inappropriate use and independent variables. Multiple Logistic Regression was also performed. The proportion of inappropriate use of Emergency Services was 73.4% and was associated with people with some primary health care sensitive conditions, residents in areas without primary care coverage, people between 0 and 11 years old, and 12 to 17 years old, care in the first trimester of the year, respiratory diseases, lesions and poisonings and diseases of the musculoskeletal system. Primary care must be strengthened to reduce the inappropriate use of care, especially in the attention to primary health care sensitive conditions and to increase the socio-organizational accessibility.

Key words
Emergency medical services; Primary health care; Health evaluation

Introduction

The increase in the search for emergency services (ES) can be considered a global phenomenon. The assistance provided by emergency services to users with non-urgent clinical conditions¹1 Unwin M, Nurs GD, Kinsman L. Rigby S, Nurs GC. Why are we waiting? Patients' perspectives for accessing emergency department services with non-urgent complaints. Int EmergNurs 2016 [cited 2018 Mar 15]. 29:3-8. Available from: https://www.sciencedirect.com/science/article/pii/S1755599X16300994?via%3Dihub
https://www.sciencedirect.com/science/ar...

2 Cremonesi P, Bella E, Montefiori M, Persico L. The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments. Appl Health Econ Health Policy 2015 [cited 2018 Mar 20]. 13(5):507-514. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25854901
https://www.ncbi.nlm.nih.gov/pubmed/2585...

3 Freed G, Gafforini S, Carson N. Age-related variation in primary care type presentations to emergency departments. Aust Fam Physician 2015 [cited 2018 Fev 20]; 44(8):584-588. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26510148
https://www.ncbi.nlm.nih.gov/pubmed/2651...

4 Parry YK, Ullah S, Raftos J, Willis E. Deprivation and its impact on non-urgent Paediatric Emergency Department use: are Nurse Practitioners the answer? J Adv Nurs 2016 [cited 2018 Mar 14]; 72(1):99-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26383900
https://www.ncbi.nlm.nih.gov/pubmed/2638... ^-55 Alyasin A, Douglas C. Reasons for non-urgent presentations to the emergency department in Saudi Arabia. Int Emerg Nurs 2014 [cited 2018 Mar 12]; 22(4):220-225. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24703789
https://www.ncbi.nlm.nih.gov/pubmed/2470... characterizes the inappropriate use of urgency/emergency services.

Urgency/emergency services aim to perform procedures to immediately stabilize specific clinical conditions, but not in a continuous manner⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... . However, people often seek ES for immediate attention, regardless of whether it is an acute or aggravated chronic situation, which causes problems in the provision of this type of service⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... . Evidence shows that the inappropriate use of ES ranges from 24% to 40%, with peaks of up to 90% of all assistance provided²2 Cremonesi P, Bella E, Montefiori M, Persico L. The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments. Appl Health Econ Health Policy 2015 [cited 2018 Mar 20]. 13(5):507-514. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25854901
https://www.ncbi.nlm.nih.gov/pubmed/2585... ^,44 Parry YK, Ullah S, Raftos J, Willis E. Deprivation and its impact on non-urgent Paediatric Emergency Department use: are Nurse Practitioners the answer? J Adv Nurs 2016 [cited 2018 Mar 14]; 72(1):99-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26383900
https://www.ncbi.nlm.nih.gov/pubmed/2638... ^,66 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... .

In countries such as the United States, Canada, the United Kingdom and Australia, the demand for emergency services has increased by 3 to 6% per year⁷7 Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? a rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med 2017 [cited 2018 Mar 13]; 24(9): 1137-1149. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599959/
https://www.ncbi.nlm.nih.gov/pmc/article... . Its consequence is the overcrowding of services and a longer waiting time⁷7 Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? a rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med 2017 [cited 2018 Mar 13]; 24(9): 1137-1149. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599959/
https://www.ncbi.nlm.nih.gov/pmc/article... ^,88 Hui Jade Kua P, Wu L, Tessa Ong E-L, Ying Lim Z, Luther Yiew J, Hui Michelle Thia X, et al. Understanding decisions leading to nonurgent visits to the paediatric emergency department: caregivers' perspectives. Singapore Med J [Internet]. 2016 [cited 2019 May 24]; 57(6):314-319. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971450/pdf/SMJ-57-314.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... , increased costs for the health system²2 Cremonesi P, Bella E, Montefiori M, Persico L. The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments. Appl Health Econ Health Policy 2015 [cited 2018 Mar 20]. 13(5):507-514. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25854901
https://www.ncbi.nlm.nih.gov/pubmed/2585... , dissatisfaction of users⁸8 Hui Jade Kua P, Wu L, Tessa Ong E-L, Ying Lim Z, Luther Yiew J, Hui Michelle Thia X, et al. Understanding decisions leading to nonurgent visits to the paediatric emergency department: caregivers' perspectives. Singapore Med J [Internet]. 2016 [cited 2019 May 24]; 57(6):314-319. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971450/pdf/SMJ-57-314.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... and precarious care for urgent cases⁴4 Parry YK, Ullah S, Raftos J, Willis E. Deprivation and its impact on non-urgent Paediatric Emergency Department use: are Nurse Practitioners the answer? J Adv Nurs 2016 [cited 2018 Mar 14]; 72(1):99-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26383900
https://www.ncbi.nlm.nih.gov/pubmed/2638... ^,88 Hui Jade Kua P, Wu L, Tessa Ong E-L, Ying Lim Z, Luther Yiew J, Hui Michelle Thia X, et al. Understanding decisions leading to nonurgent visits to the paediatric emergency department: caregivers' perspectives. Singapore Med J [Internet]. 2016 [cited 2019 May 24]; 57(6):314-319. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971450/pdf/SMJ-57-314.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... .

In Brazil, the scarcity of studies on the inappropriate use in emergency services due to the lack of information on the use of hospital emergency services and Emergency Care Units (ECUs) affects the organization and functioning of the network of emergency and urgency services, consequently affecting the results of the care provided. The analysis of the reasons that lead users to seek for ES is important to identify the problems in this network.

The ECU, which counts with 24-hour services, must primarily: welcome users and family members in urgency and emergency situations, whenever they seek assistance; articulate with other services of care assistance and with diagnostic and therapeutic support services; provide efficient and qualified assistance to users affected by either acute conditions of a clinical, surgical and trauma nature; provide diagnostic and therapeutic support and refer to other services when necessary⁹9 Brasil. Ministério da Saúde. Portaria n. 10, de 3 de janeiro de 2017. Redefine as diretrizes de modelo assistencial e financiamento de UPA 24h de Pronto Atendimento como Componente da Rede de Atenção às Urgências, no âmbito do Sistema Único de Saúde. Brasília: MS;2017 [acessado 2018 fev 5]. Disponível em: http://http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt0010_03_01_2017.html
http://bvsms.saude.gov.br/bvs/saudelegis... . Since it is a structure of intermediate complexity involving both the PHC and the hospital services, the observation the use of emergency services can subsidize the improvement of care flows.

The population can choose urgency and emergency services due to several reasons, which are related to a greater socio-organizational accessibility (opening hours, waiting time and availability of professionals, especially the physician) when compared with Primary Health Care (PHC), lack of confidence in PHC; perception of emergency-based services as needed; opinions of family/friends/health professionals; proximity to the ECU; agility in referral to specialists and exams, difficulty in scheduling appointments in PHC, convenience for the user or lack of knowledge about the flow of care in different levels of health care⁷7 Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? a rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med 2017 [cited 2018 Mar 13]; 24(9): 1137-1149. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599959/
https://www.ncbi.nlm.nih.gov/pmc/article... ^,1010 Colineaux H, Querrec FL, Pourcel L, Gallart JC, Azéma O, Lang T, Kelly-Irving M, Charpentier S, Lamy S. Is the use of emergency departments socially patterned? Int J Public Health 2018 [cited 2018 Ago 02]; 63(3): 397-407. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29332173
https://www.ncbi.nlm.nih.gov/pubmed/2933... ^,1111 Chapman B, Turnbull T. Health professionals' perceptions of inappropriate use of A&E services. Br J Nurs 2016 [cited 2018 Mar 15]; 25(9):476-483. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27172488
https://www.ncbi.nlm.nih.gov/pubmed/2717... , problems in structuring the assistance network, in the coordination and integrality of the health care¹²12 Hudon C, Sanche S, Haggerty JL. Personal characteristics and experience of primary care predicting frequent use of emergency department: a prospective cohort study. PLoS One 2016 [cited 2019 May 24];11(6):e0157489. Available from: http://dx.doi.org/10.5061/dryad
http://dx.doi.org/10.5061/dryad... .

Moreover, this analysis can be done by means of health indicators, such as the Primary Care Sensitive Conditions (PCSC), which are commonly used as an indicator of hospital care and characterized by a group of causes and diagnoses that can be managed in the PHC¹³13 Brasil. Ministério da Saúde. Portaria n. 221, de 17 de abril de 2018. Dispõe sobre as internações por Condições Sensíveis à Atenção Primária. Brasília; 2018 [acessado 2018 fev 5]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/sas/2008/prt0221_17_04_2008.html
http://bvsms.saude.gov.br/bvs/saudelegis... in a timely manner, without the need for assistance in emergency care units, except in acute situations, which are characterized as urgency and emergency.

Although the use of ES may seem appropriate from the patient’s point of view, given the limitations that exist at other levels of health care, this type of use increases the demand for services that could be better managed at other levels and divides attention with real emergency cases⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... . Therefore, our study aims to analyze factors associated with inappropriate use of emergency services.

Material and methods

This cross-sectional study used data from medical records of patients seen at two ECU in a municipality in the center-south of Paraná, from January 1 to December 31, 2013.

The urgency and emergency services of the municipality are linked to the Urgency and Emergency Network of the region, offer 24-hour service, uninterrupted, for users of all ages, and use the reception with triage according to the severity. In 2013, 173,462 assistances were recorded.

The sample was estimated randomly using the probability technique; considering a 95% level of significance, a 5% error and a sample of at least 384 records were determined. The study population corresponded to the users assisted in the two ECUs in the city. The sample was stratified proportionally to the number of assistances between January and December 2013. To complete the sampling and randomization process, for each month, the internal selection to the strata followed simple random sampling.

Data collection from medical records occurred in May and June 2014. After the sample selection, 18 medical records were excluded because they corresponded to the same user. In this case, only the medical records for the first assistance provided for this user in the year were included. Thirteen medical records were excluded due to incomplete data. Thus, a new random sampling was performed to include 31 medical records and complete the sample of 384 records.

The assistances provided by the emergency services were categorized into two groups: appropriate or inappropriate. To classify an emergency service as appropriate, at least one of the following four criteria should be considered, based on a systematic review on the topic⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... : a) Presence of a complaint of urgency/emergency, in which the user demanded immediate attention, with risk of death or functional injuries, according to the professional service report (medical and nursing) (the Manchester Triage System helped in the definition of the case, with red, orange or yellow risk being considered as appropriate use); b) Vital signs outside normal thresholds and related to the main complaint, according to the age group; c) Professional conduct adopted related to the main complaint (observation for more than 12 hours or hospitalization); and d) Need for immediate diagnostic tests or special treatment (for example, intravenous medication, O₂). If the assistances provided did not meet at least one of the criteria described above, it was classified as inappropriate.

Medical records were analyzed independently by two researchers, with subsequent discussion of each medical record. In case of disagreements regarding the classification of appropriate use or not, experts in the field (specialists in urgency and emergency care) were consulted to reassess the medical record and define the final classification.

The following variables were collected from the medical records: gender, date, time and day of the week of assistance, age group, existence of a PHC unit of reference for the user, diagnosis of assistance in the ES (according to the Tenth Revision of the International Classification of Diseases and Health-Related Problems - ICD-10), between May and June 2014. The information was inserted in the Microsoft Office Excel® 2013 for Windows® Program.

The Brazilian List of Primary Care Sensitive Conditions¹³13 Brasil. Ministério da Saúde. Portaria n. 221, de 17 de abril de 2018. Dispõe sobre as internações por Condições Sensíveis à Atenção Primária. Brasília; 2018 [acessado 2018 fev 5]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/sas/2008/prt0221_17_04_2008.html
http://bvsms.saude.gov.br/bvs/saudelegis... was consulted to classify the diagnosis described in each medical record as being or not a CSAP and characterize this variable. By analyzing the date, time and day of the week of the service, the PHC could be categorize as open or closed, considering that the PHC units operated from Monday to Friday, except holidays, from 8:00 am to 12:00 and from 1:00 pm to 5:00 pm in the municipality surveyed. Regarding the PHC coverage, the city coverage map was requested from the Municipal Health Department, and it was determined if the user belonged to the covered area or not based on the user’s place of residence.

The variables were described with frequencies and percentages. The association between inappropriate use of services in the ECU according to independent variables was assessed using the Chi-square test. Multivariate analysis was performed by logistic regression models using the stepwise forward model, which estimated the Odds Ratio (OR) and respective confidence intervals (CI). Variables with p<0,20 were included in the model in the bivariate analysis. The variables that remained significant (p<0,05) or that fitted the model were maintained in the final model. The adequacy of the final models was verified using the deviance and Hosmer-Lemeshow tests, the collinearity of the variables was tested with the variance inflation factor (VIF) and the statistical analyses performed with the Stata software version 12.

The research was approved by the Research Ethics Committee of the State University of the Midwest.

Results

In 2013, 173,462 assistances were provided at the two emergency care units in the investigated municipality, with an average of 475 assistances/day. Of the 384 assistances included in the study, the proportion of inappropriate use of ES was 73,4% (Table 1).

Regarding the characterization of the assistances, they were mostly provided from Monday to Friday (74,2%), when the Health Centers (HC) were closed (62,8%), and for people living in areas covered by PHC (87%). The predominant age from 18 to 39 years old (30,5%). Among the conditions, 51% were CSPC, and according to the chapters of ICD-10, the main diseases were: diseases of the respiratory system (22,4%), symptoms, signs and abnormal findings of clinical and laboratory tests, not classified in another part (20,8%) and injuries, poisonings and some other consequences of external causes (10,2%) (Table 1).

The bivariate analysis showed that PCSC (p<0,001), area not covered by the PHC (p=0,009), 1st quarter of the year (p=0,013), age range from 0 to 11 years (p=0,006) and age from 12 to 17 years (p=0,159), and the main diagnoses, namely diseases of the respiratory system (p<0,001), injuries and poisonings (p<0,001) and external causes (p=0,015), were associated with the use of emergency services (Table 2).

The logistic regression analysis showed that the inappropriate use of ES was associated with people assisted due to a PCSC (OR=2,55). Moreover, it was associated with those living in areas without PHC coverage (OR=2,30), people aged between 0 and 11 years old (OR=4,37), and between 12 and 17 years old (OR=3,67), diseases of the respiratory system (OR=3.82), and diseases of the musculoskeletal system (OR=3,19), and to protective effects for assistance in the first quarter of the year (OR=0,40) and injuries and poisonings (OR=0,11) (Table 3).

Discussion

The inappropriate use of ES has been studied for more than two decades. It is a worldwide concern discussed in several countries with different health contexts⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... ^,1010 Colineaux H, Querrec FL, Pourcel L, Gallart JC, Azéma O, Lang T, Kelly-Irving M, Charpentier S, Lamy S. Is the use of emergency departments socially patterned? Int J Public Health 2018 [cited 2018 Ago 02]; 63(3): 397-407. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29332173
https://www.ncbi.nlm.nih.gov/pubmed/2933... ^,1414 Read JG, Varughese S, Cameron PA. Determinants of non-urgent Emergency Department attendance among females in Qatar. Qatar Med J. 2014 [cited 2018 Abr 21]; 2014(2):98-105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25745599
https://www.ncbi.nlm.nih.gov/pubmed/2574... . In our study, we observed a high proportion of inappropriate use of emergency care services, which corroborates the literature⁵5 Alyasin A, Douglas C. Reasons for non-urgent presentations to the emergency department in Saudi Arabia. Int Emerg Nurs 2014 [cited 2018 Mar 12]; 22(4):220-225. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24703789
https://www.ncbi.nlm.nih.gov/pubmed/2470... ^,1515 Machado GVC, Oliveira FLP, Barbosa HAL, Giatti L, Bonolo PF. Fatores associados à utilização de um serviço de urgência/emergência. Cad Saude Colet 2015 [acessado 2018 abr 18]; 23(4):416-424. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-462X2015000400416&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S141... ^,1616 Garcia VM, Reis RK. Adequação da demanda e perfil de morbidade atendida em uma unidade não hospitalar de urgência e emergência. Cien Cuid Saude 2014 [acessado 2018 abr 18]. 13(4):665-673. Disponível em: http://dx.doi.org/10.4025/cienccuidsaude.v13i4.19127
http://dx.doi.org/10.4025/cienccuidsaude... .

The proportions found in the studies may be related especially to the methods used to determine situations of inappropriate use⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... , which are characterized by non-urgency or emergency situations assisted in emergency services¹1 Unwin M, Nurs GD, Kinsman L. Rigby S, Nurs GC. Why are we waiting? Patients' perspectives for accessing emergency department services with non-urgent complaints. Int EmergNurs 2016 [cited 2018 Mar 15]. 29:3-8. Available from: https://www.sciencedirect.com/science/article/pii/S1755599X16300994?via%3Dihub
https://www.sciencedirect.com/science/ar... ^,22 Cremonesi P, Bella E, Montefiori M, Persico L. The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments. Appl Health Econ Health Policy 2015 [cited 2018 Mar 20]. 13(5):507-514. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25854901
https://www.ncbi.nlm.nih.gov/pubmed/2585... ^,55 Alyasin A, Douglas C. Reasons for non-urgent presentations to the emergency department in Saudi Arabia. Int Emerg Nurs 2014 [cited 2018 Mar 12]; 22(4):220-225. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24703789
https://www.ncbi.nlm.nih.gov/pubmed/2470... , that is, they do not constitute acute conditions of a clinical, surgical or traumatic nature⁹9 Brasil. Ministério da Saúde. Portaria n. 10, de 3 de janeiro de 2017. Redefine as diretrizes de modelo assistencial e financiamento de UPA 24h de Pronto Atendimento como Componente da Rede de Atenção às Urgências, no âmbito do Sistema Único de Saúde. Brasília: MS;2017 [acessado 2018 fev 5]. Disponível em: http://http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt0010_03_01_2017.html
http://bvsms.saude.gov.br/bvs/saudelegis... .

Despite being defined in the literature, there are still controversies about the criteria for classifying cases of inappropriate use of emergency services¹⁰10 Colineaux H, Querrec FL, Pourcel L, Gallart JC, Azéma O, Lang T, Kelly-Irving M, Charpentier S, Lamy S. Is the use of emergency departments socially patterned? Int J Public Health 2018 [cited 2018 Ago 02]; 63(3): 397-407. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29332173
https://www.ncbi.nlm.nih.gov/pubmed/2933... . In our study, the severity criteria were adopted to classify the inappropriate or appropriate use of the ES, based on strict criteria disseminated in the literature⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... . This rigor is important when considering the construction of local health systems guided by PHC, since it allows the understanding of the role of each level of care, such as in a study conducted in France, which analyzed the assistance provided in emergency services and found that non-urgent situations assisted in ES could be managed by general practitioners in PHC¹⁰10 Colineaux H, Querrec FL, Pourcel L, Gallart JC, Azéma O, Lang T, Kelly-Irving M, Charpentier S, Lamy S. Is the use of emergency departments socially patterned? Int J Public Health 2018 [cited 2018 Ago 02]; 63(3): 397-407. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29332173
https://www.ncbi.nlm.nih.gov/pubmed/2933... .

Our study showed that people assisted due to some PCSC had a greater chance of inappropriate use of the emergency services. A study in a municipality of Paraná pointed out that the presence of chronic morbidity and lack of physicians in Health Centers are factors associated with the inappropriate use of ES by older adults with PCSC¹⁷17 Rêgo AS, Rissardo LK, Scolari GAS, Sanches RCN, Carreira L, Radovanovic CAT. Fatores associados ao atendimento a idosos por condições sensíveis à Atenção Primária à Saúde. Rev Bras Geriatr Gerontol 2017 [acessado 2018 fev 18]; 20(6):778-789. Disponível em: http://www.scielo.br/scielo.php?pid=S1809-98232017000600773&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S180... . On the other hand, the increase in the density of general practitioners and the structuring of the care network affect the reduction of hospitalizations due to PCSC¹⁸18 Burgdorf F, Sundmacher L. Potentially Avoidable Hospital Admissions in Germany An Analysis of Factors Influencing Rates of Ambulatory Care Sensitive Hospitalizations. Dtsch Arztebl Int 2014 [cited 2019 May 24];111(13):215-223. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991158/pdf/Dtsch_Arztebl_Int-111-0215.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... .

The aggravation of a PCSC is characterized as a case of appropriate use of the ES, since this service is structured to meet situation of urgency and emergency. However, such occurrence indicates failures in the management and control of such diseases in the PHC context, showing the weakness of this level of attention in the control of the PCSC.

PHC must be constantly evaluated to encourage improvements to perform its role. If the PCSC were assisted in PHC, the risk of aggravation and subsequent exacerbation, which leads to the demand for assistance in emergency care units and/or hospitalization, would be reduced¹⁹19 Costa JSD, Pattussi MP, Morimoto T, Arruda JS, Bratkowski GR, Sopelsa M, Fritzen JS, Canto VAF, Marques MC. Tendência das internações por condição sensível à atenção primária e fatores associados em Porto Alegre, RS, Brasil. Cien Saude Colet 2016 [acessado 2018 mar 12]; 21(4):1289-1296. Disponível em: http://www.scielo.br/scielo.php?pid=S1413-81232016000401289&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S141... . Moreover, when a user seeks an ES frequently and due to non-urgency situations, the user does not have a continuous care such as that offered by the PHC.

PCSCs are responsible for most hospitalizations due to clinical conditions, and the financial investment in the Unified Health System, expansion of the FHS and the More Doctors program has important influence on reducing these hospitalizations²⁰20 Gonçalves MR, Hauser L, Prestes IV, Schmidt MI, Duncan BB, Harzheim E. Primary health care quality and hospitalizations for ambulatory care sensitive conditions in the public health system in Porto Alegre. Brazil Fam Pract 2016 [cited 2018 Apr 21]; 33(3):238-242. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26124441.
https://www.ncbi.nlm.nih.gov/pubmed/2612... ^,2121 Paim Brasil V, Soares Dias da Costa J. Hospitalizações por condições sensíveis à atenção primária em Florianópolis, Santa Catarina - estudo ecológico de 2001 a 2011. Epidemiol Serv Saude 2016;25(1):10-11., strategies that value and strengthen the PHC.

Our results suggest that, by providing and effective care to PCSCs at PHC, the benefits will be not only the reduction of hospitalizations, but also the reduction of the assistances provided at other levels of care²⁰20 Gonçalves MR, Hauser L, Prestes IV, Schmidt MI, Duncan BB, Harzheim E. Primary health care quality and hospitalizations for ambulatory care sensitive conditions in the public health system in Porto Alegre. Brazil Fam Pract 2016 [cited 2018 Apr 21]; 33(3):238-242. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26124441.
https://www.ncbi.nlm.nih.gov/pubmed/2612... , with reduced costs and improved quality of health care²2 Cremonesi P, Bella E, Montefiori M, Persico L. The Robustness and Effectiveness of the Triage System at Times of Overcrowding and the Extra Costs due to Inappropriate Use of Emergency Departments. Appl Health Econ Health Policy 2015 [cited 2018 Mar 20]. 13(5):507-514. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25854901
https://www.ncbi.nlm.nih.gov/pubmed/2585... ^,2222 Rudge GM, Mohamed MA, Fillingham SC, Girling A, Sidhu K, Stevens AJ. The combined influence of distance and neighbourhood deprivation on Emergency Department attendance in a large English population: a retrospective database study. Plos One. 2013 [cited 2018 Apr 21]; 8(7):e67943. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23874473
https://www.ncbi.nlm.nih.gov/pubmed/2387... .

Inadequate service requests are among the causes of inefficiency in the health system, since a significant portion of health expenses is reserved for procedures considered unnecessary. The user’s initial intention when seeking a health service may differ from the action that would be more appropriate in terms of the organization of the system, which generates an inopportune cost²³23 Guimarães DS, Soares EJ, Júnior GF, Medeiros DD. Attributes and circumstances that induce inappropriate health services demand: a study of the health sector in Brazil. BMC Health Serv Res 2015; 15:65 [cited 2018 Apr 15]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339295/
https://www.ncbi.nlm.nih.gov/pmc/article... . Health services must then be reorganized with PHC valuation, since the users seek care at the health service that best meets their desires when the PHC does not offer a structured, effective and timely service.

Our results also showed that users in regions without PHC coverage have a greater chance of inappropriate use of emergency services. This can be explained by the lack of regular access to primary care, which results in the search for ES for any condition or problem⁴4 Parry YK, Ullah S, Raftos J, Willis E. Deprivation and its impact on non-urgent Paediatric Emergency Department use: are Nurse Practitioners the answer? J Adv Nurs 2016 [cited 2018 Mar 14]; 72(1):99-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26383900
https://www.ncbi.nlm.nih.gov/pubmed/2638... , regardless of the severity, a common situation in low-income countries¹⁴14 Read JG, Varughese S, Cameron PA. Determinants of non-urgent Emergency Department attendance among females in Qatar. Qatar Med J. 2014 [cited 2018 Abr 21]; 2014(2):98-105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25745599
https://www.ncbi.nlm.nih.gov/pubmed/2574... . Most of users assisted in ES could receive a care service without the need for accurate technological resources, which would reduce the overcrowding of emergency services³3 Freed G, Gafforini S, Carson N. Age-related variation in primary care type presentations to emergency departments. Aust Fam Physician 2015 [cited 2018 Fev 20]; 44(8):584-588. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26510148
https://www.ncbi.nlm.nih.gov/pubmed/2651... .

Despite the scarcity of literature on the influence of PHC actions in the search for emergency sectors, there is interest in interventions that facilitate the proper use of emergency services. Studies have reported that empowerment or user-centered care can reduce this inadequacy¹²12 Hudon C, Sanche S, Haggerty JL. Personal characteristics and experience of primary care predicting frequent use of emergency department: a prospective cohort study. PLoS One 2016 [cited 2019 May 24];11(6):e0157489. Available from: http://dx.doi.org/10.5061/dryad
http://dx.doi.org/10.5061/dryad... . In the United States, the distribution of educational materials with instructions on how to deal with simple problems by themselves and how to decide when to seek for ES have helped to improve the flow of care in ECUs²⁴24 Yoffe SJ, Moore RW, Gibson JO, Dadfar NM, McKay RL, McClellan DA et al. A reduction in emergency department use by children from a parent educational intervention. Fam Med 2011 [cited 2018 Mar 21]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21305425/
https://www.ncbi.nlm.nih.gov/pubmed/2130... . The development of information and communication technologies can be tools that provide information to users and have been able to assist in decision making, such as mobile health tools (m-health) and online medical advice platforms²³23 Guimarães DS, Soares EJ, Júnior GF, Medeiros DD. Attributes and circumstances that induce inappropriate health services demand: a study of the health sector in Brazil. BMC Health Serv Res 2015; 15:65 [cited 2018 Apr 15]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339295/
https://www.ncbi.nlm.nih.gov/pmc/article... . Despite these efforts, difficulties in the adequate demand for ES still increase in many countries⁷7 Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? a rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med 2017 [cited 2018 Mar 13]; 24(9): 1137-1149. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599959/
https://www.ncbi.nlm.nih.gov/pmc/article... .

In Brazil, ECUs have been built since 2009, which should be strategically installed to configure the emergency care network, differentiating from emergency services, which produce “emergency consultations”²⁵25 Konder MT, O'Dwyer G. As Unidades de Pronto-Atendimento na Política Nacional de Atenção às Urgências. Physis. 2015 [acessado 2018 abr 19]; 25(2):525-545. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312015000200525&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... . However, the implementation process was accelerated, without accomplishing the purpose of organizing the network, which resulted in the reproduction of the traditional emergency service model and had little positive effect on coping with the problems of providing care to emergency situations²⁵25 Konder MT, O'Dwyer G. As Unidades de Pronto-Atendimento na Política Nacional de Atenção às Urgências. Physis. 2015 [acessado 2018 abr 19]; 25(2):525-545. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-73312015000200525&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... .

The overcrowding of ES due to causes that can be assisted in PHC implies a PHC underutilization, and the consequent overload of emergency services, both regarding the work of urgency and emergency teams and regarding the costs for the health system¹⁰10 Colineaux H, Querrec FL, Pourcel L, Gallart JC, Azéma O, Lang T, Kelly-Irving M, Charpentier S, Lamy S. Is the use of emergency departments socially patterned? Int J Public Health 2018 [cited 2018 Ago 02]; 63(3): 397-407. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29332173
https://www.ncbi.nlm.nih.gov/pubmed/2933... ^,2222 Rudge GM, Mohamed MA, Fillingham SC, Girling A, Sidhu K, Stevens AJ. The combined influence of distance and neighbourhood deprivation on Emergency Department attendance in a large English population: a retrospective database study. Plos One. 2013 [cited 2018 Apr 21]; 8(7):e67943. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23874473
https://www.ncbi.nlm.nih.gov/pubmed/2387... .

In addition to the specific aspects of the inappropriate use of ES, the specific issues of PHC structuring and instrumentalization must be evidenced. One of the challenges faced by the Brazilian health system is to make PHC a gateway for users, which allows it to assist most of health problems. The scarcity of resources due to underfunding and the lack of effectiveness overload other levels of attention and directly influences the quality of the service provided¹⁵15 Machado GVC, Oliveira FLP, Barbosa HAL, Giatti L, Bonolo PF. Fatores associados à utilização de um serviço de urgência/emergência. Cad Saude Colet 2015 [acessado 2018 abr 18]; 23(4):416-424. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-462X2015000400416&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S141... ^,1717 Rêgo AS, Rissardo LK, Scolari GAS, Sanches RCN, Carreira L, Radovanovic CAT. Fatores associados ao atendimento a idosos por condições sensíveis à Atenção Primária à Saúde. Rev Bras Geriatr Gerontol 2017 [acessado 2018 fev 18]; 20(6):778-789. Disponível em: http://www.scielo.br/scielo.php?pid=S1809-98232017000600773&script=sci_abstract&tlng=pt.
http://www.scielo.br/scielo.php?pid=S180... ^,2626 Oliveira AMS, Menezes TMO. The nurse in the elderly care of the family health strategy: meanings of the experience. Rev Enferm UERJ 2014 [cited 2018 Apr 21]; 22(4):513-518. Available from: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/15373/11629
http://www.e-publicacoes.uerj.br/index.p... .

PHC has been recognized as a central component of effective health systems since the beginning of the 20th century. However, despite the remarkable progress, there is still a big gap between the necessities of the individuals and communities and the quality of care provided²⁷27 Bitton A, Ratcliffe HL, Veillard JH, Kress DH, Barkley S, Kimball M, Secci F, Wong E, Basu L, Taylor C, Bayona J, Wang H, Lagomarsino G, Hirshhorn LR. Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries. J Gen Intern Med 2016 [cited 2019 Abr 23];32(5):566-571. Available from: https://link.springer.com/content/pdf/10.1007%2Fs11606-016-3898-5.pdf
https://link.springer.com/content/pdf/10... .

Brazil has considerable flaws in the way primary care is organized, financed and provided, and these issues are associated with problems in the performance of the health system, including the medical assistance in a timely and effective manner²⁸28 Macinko J, Guanais FC, Mullachery P, Jimenez G. Gaps in primary care and health system performance in six latin American and Caribbean countries. Health Aff 2016;35(8):1513-1521.. PHC still has high levels of organizational barriers, lack of continuity of care, especially due to difficulties in the stability of professionals at this level of care. Another important problem is the lack of coordination of care, which reflects the challenge of successfully incorporating secondary prevention and advanced diagnostic services in PHC²⁸28 Macinko J, Guanais FC, Mullachery P, Jimenez G. Gaps in primary care and health system performance in six latin American and Caribbean countries. Health Aff 2016;35(8):1513-1521..

Our study found an association between two age groups, 0 to 11 years and 12 to 17 years, with inappropriate use of ES, which corroborates the findings from other studies³3 Freed G, Gafforini S, Carson N. Age-related variation in primary care type presentations to emergency departments. Aust Fam Physician 2015 [cited 2018 Fev 20]; 44(8):584-588. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26510148
https://www.ncbi.nlm.nih.gov/pubmed/2651... ^,44 Parry YK, Ullah S, Raftos J, Willis E. Deprivation and its impact on non-urgent Paediatric Emergency Department use: are Nurse Practitioners the answer? J Adv Nurs 2016 [cited 2018 Mar 14]; 72(1):99-106. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26383900
https://www.ncbi.nlm.nih.gov/pubmed/2638... ^,1515 Machado GVC, Oliveira FLP, Barbosa HAL, Giatti L, Bonolo PF. Fatores associados à utilização de um serviço de urgência/emergência. Cad Saude Colet 2015 [acessado 2018 abr 18]; 23(4):416-424. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-462X2015000400416&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S141... ^,1616 Garcia VM, Reis RK. Adequação da demanda e perfil de morbidade atendida em uma unidade não hospitalar de urgência e emergência. Cien Cuid Saude 2014 [acessado 2018 abr 18]. 13(4):665-673. Disponível em: http://dx.doi.org/10.4025/cienccuidsaude.v13i4.19127
http://dx.doi.org/10.4025/cienccuidsaude... . In Australia, the use of emergency sectors for situations not characterized as urgency decreases proportionally with user’s aging³3 Freed G, Gafforini S, Carson N. Age-related variation in primary care type presentations to emergency departments. Aust Fam Physician 2015 [cited 2018 Fev 20]; 44(8):584-588. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26510148
https://www.ncbi.nlm.nih.gov/pubmed/2651... . Older adults are more closely monitored for chronic conditions by PHC, which reduces the chances of an inappropriate use of the ES¹⁵15 Machado GVC, Oliveira FLP, Barbosa HAL, Giatti L, Bonolo PF. Fatores associados à utilização de um serviço de urgência/emergência. Cad Saude Colet 2015 [acessado 2018 abr 18]; 23(4):416-424. Disponível em: http://www.scielo.br/scielo.php?pid=S1414-462X2015000400416&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S141... .

The search for care for children and adolescents in the ES for non-urgency conditions involves the evaluation of the caregiver/guardian about the benefits and disadvantages of attending an ES compared to the service in the PHC. Moreover, this assessment is influenced by both the perception of the severity of the disease and the availability of the service at the time the user considers it necessary⁸8 Hui Jade Kua P, Wu L, Tessa Ong E-L, Ying Lim Z, Luther Yiew J, Hui Michelle Thia X, et al. Understanding decisions leading to nonurgent visits to the paediatric emergency department: caregivers' perspectives. Singapore Med J [Internet]. 2016 [cited 2019 May 24]; 57(6):314-319. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971450/pdf/SMJ-57-314.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... .

There are difficulties in accessing PHC by adolescents due to problems in geographic and organizational accessibility²⁹29 Martins MMF, Aquino R, Pamponet ML, Pinto Junior EP, Amorim LDAF. Acesso aos serviços de atenção primária à saúde por adolescentes e jovens em um município do Estado da Bahia, Brasil. Cad Saude Publica 2019 [acessado 31 maio 2019]; 35(1):e00044718. Disponível em: https://cidades.ibge.gov.br/brasil/ba/camaca
https://cidades.ibge.gov.br/brasil/ba/ca... and friendly services for them must be urgently prioritized, such as opening hours that allow young people to leave during class hours and professionals with skills to work with that specific audience. In general, these services should be provided in a way that is available to adolescents, but also acceptable and accessible³⁰30 James S, Pisa PT, Imrie J, Beery MP, Martin C, Skosana C, et al. Assessment of adolescent and youth friendly services in primary healthcare facilities in two provinces in South Africa. BMC Health Serv Res 2018 [cited 2019 May 31]; 18(1):809. Available at: http://www.ncbi.nlm.nih.gov/pubmed/30348166
http://www.ncbi.nlm.nih.gov/pubmed/30348... .

The knowledge of caregivers/guardians about both the child health issues⁸8 Hui Jade Kua P, Wu L, Tessa Ong E-L, Ying Lim Z, Luther Yiew J, Hui Michelle Thia X, et al. Understanding decisions leading to nonurgent visits to the paediatric emergency department: caregivers' perspectives. Singapore Med J [Internet]. 2016 [cited 2019 May 24]; 57(6):314-319. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971450/pdf/SMJ-57-314.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... and the flow of emergency care in the health system must be improved, in addition to improving organizational aspects of the health system, as a way to optimize the therapeutic itinerary to be followed, especially by expanding health care of socio-organizational accessibility, such as the implementation of extended service hours in PHC.

Inappropriate use was also associated with diseases of the respiratory system, common in the region of the studied municipality, especially due to the cold climate. We also observed an association with diseases of the musculoskeletal system, which are prevalent in other studies on the subject¹1 Unwin M, Nurs GD, Kinsman L. Rigby S, Nurs GC. Why are we waiting? Patients' perspectives for accessing emergency department services with non-urgent complaints. Int EmergNurs 2016 [cited 2018 Mar 15]. 29:3-8. Available from: https://www.sciencedirect.com/science/article/pii/S1755599X16300994?via%3Dihub
https://www.sciencedirect.com/science/ar... ^,1616 Garcia VM, Reis RK. Adequação da demanda e perfil de morbidade atendida em uma unidade não hospitalar de urgência e emergência. Cien Cuid Saude 2014 [acessado 2018 abr 18]. 13(4):665-673. Disponível em: http://dx.doi.org/10.4025/cienccuidsaude.v13i4.19127
http://dx.doi.org/10.4025/cienccuidsaude... and common among workers (mostly men) in the municipality’s timber industry.

Both diseases of the respiratory and of the musculoskeletal systems constitute preventable conditions within the PHC scope¹⁶16 Garcia VM, Reis RK. Adequação da demanda e perfil de morbidade atendida em uma unidade não hospitalar de urgência e emergência. Cien Cuid Saude 2014 [acessado 2018 abr 18]. 13(4):665-673. Disponível em: http://dx.doi.org/10.4025/cienccuidsaude.v13i4.19127
http://dx.doi.org/10.4025/cienccuidsaude... , by strategies aimed at coping with diseases and conditions, with early treatment and articulation among sectors for occupational health intervention.

Injuries and poisoning, on the other hand, showed to be a protective factor for inappropriate use, which can be explained by the fact that they are acute conditions, which are adequately referenced for care in an ECU⁶6 Carret MLV, Fassa AG, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica 2009 [cited 2013 Mar 30];25(1):7-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19180283
https://www.ncbi.nlm.nih.gov/pubmed/1918... .

Assistance provided in the first quarter of the year was negatively associated with inappropriate use. The first quarter may be a protective factor against inappropriate use due to a behavioral issue, in which people, especially children, are on vacation, and therefore away from contact with other people in closed environments, which minimizes the occurrence of diseases, especially those of the respiratory system. Moreover, the municipality has a mild summer climate, with less frequent conditions typical of the intense summer weather.

Our study had some limitations, such as data collection only from medical records, which limits the association with the available data; lack of standardization among different studies on inappropriate use of ES, and the cross-sectional design of the study, which prevented the establishment of cause-and-effect relationships. Despite these limitations, we could build a greater understanding of the inappropriate use of ES and its associated factors.

Conclusions

The inappropriate use of ES can generate an imbalance of the health system, both by making it disorganized and by replicating the hegemonic curative model. Thus, understanding the factors that influence this inappropriate use is necessary since this knowledge could clarify conditions and situations that can be improved and modified in the health care network to assist users with higher quality and effectiveness, and lower costs for the system.

In our study, the results indicated a high proportion of inappropriate use of emergency services, associated with PCSC and the lack of PHC coverage, demonstrating that the weakness of PHC affects the overload of other levels of care. Moreover, the inappropriate use was associated with the age groups from 0 to 11 years and from 12 to 17 years, affected by diseases of the respiratory and of the musculoskeletal system. Care provided in the first quarter of the year and due to injuries and poisoning were protective factors against the inappropriate use of emergency services.

Ou results emphasizes the need to strengthen PHC to reduce the inappropriate use of emergency services. The redirection of non-urgency care to PHC is a desirable management goal, so that the ES concentrates efforts on users in severe situations.

References

Acknowledgment

The authors thank Espaço da Escrita - Pró-Reitoria de Pesquisa - UNICAMP - for the language services provided.

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