The overuse of emergency departments (EDs) is a global problem, raising questions of whether many of these visits could be avoided. Visits to emergency services by Portuguese citizens show very similar values over time. In 2010, there were 6411,000 ED visits, and in 2019 over 6426,000 visits.1 This scenario places Portugal as the country in the Organization for Economic Co-operation and Development (OECD) with the highest number of ED visits (over 70 visits/100 vs. an OECD mean of 31/100 population in 2011).2 Further, according to national statistics, 31% of patients admitted to the ED in Portugal are “non-urgent,” “avoidable” or “inappropriate.”2 Reducing visits of avoidable ED frequent users (ED-FU) and the number of preventable hospital visits is a priority, as they use considerable resources and are disruptive to the health system.3 In Portugal, Hospital EDs are the only place in the National Health Service (NHS) where individuals have access to a full range of services at any time, regardless of their ability to pay or the severity of their condition. Providing ambulatory health care, such as primary health care (PHC), can prevent the use of the ED through clinical measures such as preventive treatment, early diagnosis of chronic disease exacerbation and adjustment of pharmacological therapy.2–5

ED-FU, defined as having four or more visits per year, poses a challenge to emergency services as they contribute to a disproportionate number of visits.3 Several factors associated with avoidable ED-FU visits have been described in the literature and are grouped into individual-centered factors, such as sociodemographic features or disease severity, and factors associated with the health system, such as PHC resources or the proximity of the patient’s home to the ED.3 Moreover, an important question is whether ED-FU may be inflicting poor service on themselves by choosing emergency care over seeking consistent care from their own family physician. Understanding the causes related to avoidable ED-FU visits, and identifying which ones are potentially modifiable, will allow the planning and implementation of health care strategies.

ED visits due to pulmonary disease are among the most common reasons for hospitalization in developed countries.3 In Portugal, respiratory hospitalizations are one of the main reasons for visiting EDs and represent the fifth leading cause of hospitalization.6

The objective of our study was to evaluate the size and characteristics of patients with pulmonary disease as their main clinical condition overusing the ED in a university hospital in Lisbon, during the year 2019, with regard to individual-centered factors and health care-associated characteristics. A secondary objective was to identify factors associated with mortality during a follow-up since the first ED visit until December 31, 2020.

During 2019, 128,588 adult individuals visited the ED, accounting for 186,344 ED visits. Over 5567 (4.3%) patients were identified as FU, and 174 (0.14%) as ED-FU with pulmonary disease as the main clinical condition, who accounted for 1030 ED visits. These patients had a median (IQR) of 5(3) ED visits, ranging between 4 and 41. Sixty-five patients were admitted to the ED more than 5 times. One patient had 40 visits reporting respiratory symptoms.

Mortality

During the follow-up period (mean 15.7 ± 7.1 months), 78 (44.8%) patients died: 45 during 2019 (25.9%) and 33 during 2020 (25.6%). A specific analysis of this population (Table 2) showed that most patients who died were male (56.4%), retired (82.9%) and older (p<0.001). Regarding the CFS, 66.2% of individuals who died were “Moderately frail to terminally ill” patients, the vast majority (54.2%) of survivors were “Vulnerable.” The mean number of comorbidities in patients who died was higher (7.3 ± 3.5 vs. 6.0 ± 3.2, p = 0.010), the same for CCI (8.0 ± 3.0 vs. 4.5 ± 3.1, p<0.001). Of the 59 patients without a family physician, 86.4% (n = 51) died during the analysis period (< 2 years).

Table 2.

Characteristics of ED-FU according to the outcome during the follow-up and risk factors for mortality.

Outcome		Deceased78 (44.8%)		Not deceased96 (55.2%)		Univariate Modelsp-valueOR (95% CI)		Multivariate Modelsp-valueAdjusted OR (95% CI)
Demographic and socioeconomic factors
Age		73.83 ± 14.79		62.90 ± 17.69		p<0.001*
Absence of an assigned family physician		51 (65.4%)		8 (8.3%)		p<0.001*OR 20.778(8.783–49.154)		p<0.001*OR 24.394(6.777–87.805)
Clinical factors
Asthma	4 (5.1%)		23 (24.0%)		p = 0.001*OR 0.162(0.054–0.491)
Advanced cancer disease	38 (48.7%)		8 (8.3%)		p<0.001*OR 10.450(4.471–24.427)		p = 0.028*OR 7.140(1.195–42.663)
Dementia	9 (11.5%)		3 (3.1%)		p = 0.029*OR 4.043(1.055–15.492)
Other neurological disease	16 (20.5%)		8 (8.3%)		p = 0.021*OR 2.839(1.144–7.044)
Psychiatric disorder	9 (11.5%)		28 (29.2%)		p = 0.005*OR 0.317(0.139–0.721)
Arterial hypertension	57 (73.1%)		50 (52.1%)		p = 0.005*OR 2.497(1.316–4.740)
Heart failure	36 (46.2%)		30 (31.3%)		p = 0.044*OR 1.886(1.014–3.505)
Chronic kidney disease	18 (23.1%)		11 (11.5%)		p = 0.041*OR 2.318(1.021–5.262)
Number of comorbidities	7.3 ± 3.5		6.0 ± 3.2		p = 0.010*
Charlson Comorbidity Index	8.0 ± 3.0		4.5 ± 3.1		p<0.001*
Clinical Frailty Scale
Very fit/ well/ Managing well/ Vulnerable/ Mildly frail	26 (33.8%)		75 (78.1%)		p<0.001*
Moderately frail/ Severely frail/ Very severely frail/ Terminally ill	51 (66.2%)		21 (21.9%)
Autonomy deficit	52 (66.7%)		18 (18.8%)		p<0.001*OR 8.667(4.321–17.381)		p = 0.002*OR 9.149(2.115–39.571)

Legend: OR – Odds ratio, CI – Confidence Interval. *OR was calculated when p<0.05. Results are presented as number (percentage), mean ± standard deviation for variables with normal distribution.

Table 2 shows the OR for mortality before and after adjustment for age, number of comorbidities and CCI. The multiple logistic regression model identified the absence of an assigned family physician, the autonomy deficit and advanced cancer disease as the main factors associated with mortality. The Kaplan-Meier survival curve for assigned family physician, advanced cancer disease and autonomy deficit showed a different survival profile with the earliest mortality in patients with advanced cancer disease (Fig. 2).

Fig. 2.

Survival analysis with the Kaplan-Meier survival curve related to family physician assignment, advanced cancer disease and autonomy deficit (n = 174, p<0.001).

(0.25MB).

We evaluated 5567 ED-FU at one of the largest university hospitals in the country and we found that, despite generating a high number of episodes of urgency, only a small percentage of patients (3.1%; n = 174) affected by respiratory disease as the main clinical condition required hospitalization under pulmonology department accountability. To the best of our knowledge, this is the first national study to evaluate the profile of ED-FU with pulmonary disease and its impact on mortality.

The main finding was that a high proportion (33.9%) of pulmonary ED-FU did not have a family physician assigned in the PHC setting, and this was the most important factor associated with mortality. Pulmonary ED-FU were characterized by a high burden of chronic disease and disability. Advanced cancer disease and autonomy deficit were the other factors that most determined the prognosis.

An unexpected finding of our investigation was the relatively small number of patients with pulmonary disease as the main clinical condition and hospitalization (3.1%) in the group of ED-FU. A possible explanation may be related to a high and diversified care load for respiratory patients provided by our hospital center.14 However, this assumption needs to be supported by other studies comparing patient profiles and diagnosis within other national hospital institutions.

The profile of pulmonary ED-FU presented some predominant characteristics, such as a high mean age (67.8 years), male gender, social and economic vulnerability, high burden of chronic diseases and comorbidities, with a significant degree of disability and dependency. These clinical features were objectified by a high CCI (6.1 ± 3.6) with a high degree of “vulnerability” (40.5%) or “frailty” (49.7%) in the CFS. These results are in line with other series that report FU with more complaints and high prevalence of chronic diseases leading to increased use and high rates of hospitalization and mortality.15–17 COPD was the most frequent respiratory disease (48.6%), which is in agreement with national and international epidemiological data.18–22 There was a significant percentage of patients diagnosed with chronic respiratory failure (44.8%) and asthma (16.1%). Further, psychiatric disease was frequent (21.3%). A published analysis corroborates our finding that ED-FU were not simply inadequate consumers of ED resources, but were also associated with more mental health diseases and high prevalence of chronic diseases.15,23–25 The identification of social and economic vulnerability (43.7%) in our study is also supported by other studies.26–28

The analysis of the Manchester triage classification of emergency visits reflects a certain heterogeneity in these FU with pulmonary disease. Most ED episodes (77.6%) were classified as “immediate”, “very urgent” or “urgent” which may correspond to patients’ vulnerability and high burden of the disease. These contrast with 21.3% of emergency episodes categorized as “routine” or “non-urgent”, indicating that emergency services have become alternative care. According to more recent national estimates, 31% of ED visits in Portugal are “non-urgent”, “inappropriate” or “avoidable.”2 However, our finding of a much lower frequency of “routine” and “non-urgent” ED episodes (21.3%) points to a high burden of disease in ED-FU with pulmonary disease.

During the follow-up period, there was found to be a high mortality rate (44.8%). This finding supports the conclusion that the ED visit per se should not be seen as an adverse outcome and might be better perceived as a marker of the true need for health care.29 After applying the multivariate logistic regression analysis, with adjustment for age and comorbidities, we found that lack of assignment of a family physician, autonomy deficits and advanced cancer disease were associated with an increase of 24.4, 9.1 and 7.1 times in the risk of death, respectively. The identification of these three ED-FU profiles provides useful information for the development of tailored interventions that would address the specific needs of each type of ED-FU, e.g., patients with advanced cancer disease should be referred early to palliative care, avoiding multiple emergency visits.

In Portugal, the absence of an assigned family physician is a problem, in particular in the Lisbon region.30 Associated factors are the high number of retired people and a reduced capacity for generational renewal associated with low attractiveness of the general and family medicine specialty in the NHS.31 The lack of assignment of a family physician in this population of pulmonary ED-FU (33.9%) is a highly relevant factor, considering its very high mortality (86.4%). Moreover, the frequency of absence of a family physician was much higher than the national average of 7.3%, in 2019.1 Thus, frequent demand for emergency services may indicate barriers to the use of the health care network, as well as vulnerability and illness of people who repeatedly need care, with an impact on mortality.32 On the other hand, the association between mortality and high use of EDs by advanced cancer disease patients may reflect end-of-life episodes and point to a lack of palliative care services. Similarly, the autonomy deficit associated with multiple ED visits and mortality may also reflect the absence of structures that offer adequate health care to people with end-stage lung disease. These results reinforce the fact that articulation and integration of special levels of care, such as palliative and long-term care, with PHC and hospitals are relevant to ensure that these patients receive appropriate care.33–35 Home-care hospitalization (HCH) is also important in patients with end-stage disease.36,37 Despite the good development of HCH in our country, with 9 units in the Lisbon region, the number of available beds is still not sufficient.38,39

The integration of PHC and hospitals can be achieved through the creation of collaborative networks between the teams, allowing for the easier management of identified needs.

Pulmonary ED-FU are a small group of ED-FU comprising an aged and heterogeneous group, with a high burden of chronic disease and disability. The lack of assignment of a family physician in primary care setting was the most important factor associated with mortality. The clinical factors related to prognosis were advanced cancer disease and autonomy deficit. These findings support not only the urgent need to increase accessibility to a primary care physician, but also to domiciliary hospitalization, palliative care and long-term care across national health pathways.