Pattern of inappropriate cases presenting to the Accident and Emergency Department in a Nigeria Tertiary Hospital South African Family Practice is co-published by Medpharm Publications, NISC (Pty) Ltd and Cogent, Taylor & Francis Group S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 © 2015 The Author(s) RESEARCH South African Family Practice 2015; 57(4):253–258 http://dx.doi.org/10.1080/20786190.2014.978114 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC-ND 4.0] http://creativecommons.org/licenses/by-nc-nd/4.0 Pattern of inappropriate cases presenting to the Accident and Emergency Department in a Nigeria Tertiary Hospital Opunabo Nelson Young-Harrya, Paul Owajionyi Dienyeb* and Kaine Olaide Diete-Spiffb a Department of Family Medicine, Braithwaite Memorial Specialist Hospital, Port Harcourt, Nigeria b Department of Family Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria *Corresponding author, email: pdienye@yahoo.com Background: Although the primary mission of the Accident and Emergency Department (AED) is to provide initial treatment for life-threatening conditions, some patients make inappropriate use of the service. This study is aimed to determine the level of inappropriate use and the morbidity pattern of such patients presenting to the department in a tertiary hospital in Nigeria. Materials and methods: A cross-sectional descriptive study in which inappropriate users of the AED of University of Port Har- court Teaching Hospital were recruited. Data on socio-demographic characteristics and diagnoses based on ICPC-2 were collect- ed from them and analysed using SPSS version 17. Results: A total of 430 patients were recruited with age range of 18–62 years and mean of 38.45 ± 7.2 years. Considering the socio-demographic characteristics, only the association between gender and utilisation of the AED was statistically significant (p = 0.014). The prevalence of inappropriate use of the AED was 37.7%. The most frequent diagnosis among inappropriate users using the ICPC rubrics was polyuria and glycosuria (9.88%). When the cases were listed by the organ systems according to ICPC chapters, it was found that the commonest diagnoses were gastrointestinal (20.9%) and general and unspecified conditions (17.7%). Psychological conditions were not identified in this study. The most common reason for inappropriately presentation at the AED was patients referring themselves for quick attention (46.3%). Conclusions: The level of inappropriate utilisation of the accident and emergency department was very high in this institution. Creation of public awareness will curtail this sickness behaviour. Keywords: accident and emergency department, inappropriate use, morbidity, Nigeria Introduction An accident and emergency department (AED) is a medical treat- ment facility specialising in the management of sudden and unexpected illness, major injuries and life-threatening condi- tions. The department provides initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention1 without prior appointment. Although the primary mission of the accident and emergency department is well known, some patients make inap- propriate use of the service.2 They refer themselves to the department with primary care problems that are unlikely to require admission and are more suitable for other departments. The significant increase in inappropriate attendance at AEDs is considered a serious threat to the health care system, because of the resultant increased waiting times and treatment delays, impaired access, financial losses for providers, staff stress and ethical consequences.3–5 This strained and inefficient service can deprive true emergency cases of quality care. Estimating of the prevalence of these inappropriate attendances has been difficult due to varying definitions and the subjective nature of measuring inappropriateness. Internationally, the prev- alence has been reported between 24% and 40% of all AED attendances.6 Previous researchers have reported that between one to two-thirds of patients sampled attended AEDswith prob- lems that would be managed more appropriately by general practitioners (GPs).7 In a study in Hong Kong, it was found that 57% of AED attendees would have been better managed by fam- ily physicians.8 In another study in two health centres in South Essex, UK, the rate of ‘inappropriate’ attendance was 16.8% [95% confidence interval (CI): 15.7–18.0].9 The authors have not identi- fied any study on inappropriate utilisation of AED conducted in the south southern geopolitical zone of Nigeria. This study is therefore aimed to determine the level of inappropriate use and the morbidity pattern of such patients presenting to the Acci- dent and Emergency department of the University of Port Har- court Teaching Hospital, Port Harcourt, Nigeria Materials and methods Setting The study was carried out in the AED of the University of Port Harcourt Teaching Hospital, Nigeria. The department is a 22-bed facility which offers services to an average of 120 patients weekly. Some cases are managed and discharged home by the AED doc- tors within 48 h while others are admitted, resuscitated and re- ferred to the various specialist teams on call for admission into the various specialty wards. Study design: This was a cross-sectional descriptive study. Study population The study population consisted of all consenting patients aged 18 years and above who presented to the department. Inclusion criteria: All adults patients (18 years and above) who presented in the AED for treatment and consented to the study. Exclusion criteria: Unconscious patients without relations. mailto:pdienye@yahoo.com 254 S Afr Fam Pract 2015; 57(4):253–258 Patients of the paediatric age group since they are treated in the children emergency room. Sample size Using the formula; n = z2 pq/d2 for determining sample size when population is over 10 000, with a prevalence of 50% since no known prevalence study has been conducted in this environment, the determined minimum sample size was approximately 430. Sampling method Each working day, a systematic sample of patients was identified by taking every fourth registered patient until the sample size was attained. The first patient was chosen by random sampling. The process lasted for a period of three months. Procedure Ten volunteer nurses with at least one year’s experience in the accident and emergency department (AED) and had gone through training in triage were recruited and trained for one week on questionnaire administration by the researchers. Attend- ances were assigned to two groups of appropriateness as described by Dale et al.10 Primary care/inappropriate users: • Self-referred patients with symptoms likely to be caused by conditions not in need of immediate resuscitations or urgent care, and unlikely to require hospital admission. • Self-referred patients with non-urgent complications of chronic conditions. Accident and emergency/appropriate users: • All patients referred by letter or phone by a general practitioner • All emergency presentations in need of immediate care or likely to require hospital admission • Trauma requiring urgent hospital assessment (for example, frac- tured bones and dislocations, head injuries with loss of con- sciousness) Research instrument The data collection instrument was a two-part questionnaire. The first part consisted of the socio-demographic characteristics and was completed by the nurses. The second part of the instrument consisted of a structured questionnaire based on the International Classification of Primary Care – 2nd edition (ICPC-2) questionnaire as developed by the World Organisation of Family Doctors.11 ICPC-2 is a morbidity classification system designed for primary care as clinical contact in this setting does not necessarily result in a defini- tive diagnosis. The classification system is structured in 17 chapters and seven components, which remain the same for each chapter. It encompasses 686 symptoms and diagnostic rubrics. It also classi- fies data relating to patient reasons for encounter, problems man- aged, non-pharmacological treatments, referrals, and orders for pathology and imaging. Diagnoses in this study were coded using the International Classification of Primary Care (ICPC-2). Statistical analysis The questionnaires were cross-checked after each interview to ensure that they were properly completed before data entry into the computer for analysis using Statistical Package for Social Sci- ence software (Windows version 17.0; SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to describe socio-demographic characteristics of the respon dents. Appropriate charts were used to illustrate categorical variables. The Chi-square test was used to assess association between categorical variables. A p-value of < 0.05 was considered statistically significant. Ethical consideration: Ethical clearance was obtained from the Research and Ethics committee of the University of Port-Harcourt Teaching Hospital. The importance of the research was explained to the subject eligible for the study and a written consent was obtained before inclusion into the study. Results A total of 430 patients were recruited with age range of 18–62 years. Their mean age was 38.45 ± 7.2 years. Although most of the patients who used the AED were in the 20–29 years age bracket (34.65%), females (53.02%), married (47.44%), self-employed (55.81%) and with secondary education (38.37%), the association between inappropriate usage and these characteristics was not statistically significant (p > 0.05). However, there was a significant association between gender and utilisation of the AED (p = 0.014) as more females use the facility inappropriately (Table 1). The prev- alence of inappropriate use of the AED in this study was 37.7% (Figure 1). Most of the inappropriate users of AED (62.23%) attend- ed in the afternoon and night shifts. The association between the number of appropriate and inappropriate users and the different shifts was not statistically significant (p = 0.95) (Table 2). The most frequent diagnoses among inappropriate users using the ICPC rubrics was polyuria and glycosuria (9.88%), retroviral infection (9.26%), URTI (9.26%) and hypertension (9.26%). The least frequent- ly diagnosed was chronic cough (3.09%) (Table 3). When the cases were listed by the organ systems according to ICPC chapters, the most commonly diagnosed conditions were gastrointestinal (20.9%) and general and unspecified (17.7%). Inappropriate users of the AED were significantly more than appropriate users (p < 0.05). However psychological conditions were not identified in this study (Table 4). The most common reasons for inappropriate presentation at the AED were: patient referring themselves for quick attention (46.3%), inadequate medication stock at Health Centre (41.4%), check–ups given at AED are more comprehensive (32.7%) and doctors at AED being more skilful and efficient (29.0%). Proximity of AED to the residence of the patient (9.3%) was the least com- mon reason (Table 5). Discussion The inappropriate use of AEDs is a problem that has been dis- cussed widely by researchers.12, 13 Since general societal and cul- tural factors determine healthcare-seeking behaviour, interven- tions to reduce the amount of inappropriate use are likely to fail.4 Overall, the level of inappropriate utilisation of AED services in this study was 37.7%. This is within the range of between 24% and 40% reported internationally,6 but lower than 57% reported in Hong Kong8 and higher than 16.8% reported in South Essex, UK.9 These differences could be attributed to the definition of inappro- priate utilisation which may differ from one location to the other and the experience of the staff involved in the triaging. In some of the studies, the definition of inappropriate attendance was not clear enough. In the light of this fact, the most accurate assess- ment of urgency status would be achieved by having experienced emergency physicians screen patients on site. This is not possible in this study as in most developing countries considering the cost, hence nurses were used. This could have influenced the validity of the triaging process. Of all the socio-demographic characteristics considered, only gender was significantly associated with inappropriate use of the AED. This corroborates with findings in previous studies world- wide.14-16 This could be attributed to the fact that women are more available than men to attend the health facilities because they are Pattern of inappropriate cases presenting to the Accident and Emergency Department in a Nigeria Tertiary Hospital 255 more anxious of their health, or maybe more vulnerable because of their reproductive health life (e.g. child bearing, genital activities, postpartum).17 The high level of inappropriate utilisation of the AED during the afternoon and night shifts may be attributed to many factors. The Primary Health Centres in Nigeria which should cater for most of the patients are in most cases non-functional. The General Outpatient Department (GOPD) which is a primary care clinic in the teaching hospital attends to a large population of patients as compared to the AED and does not have the night shift. There is a resultant long waiting time as compared to the AED. The AED therefore becomes a safe option since services are offered round the clock. The afternoon and night shifts are also outside the office or business hours and are more convenient because most Table 1: Socio-demographic characteristics of patients attending AED Characteristics Inappropriate (%) n = 162 Appropriate (%) n = 268 Total (%) n = 430 χ2 p-value Age (years) ≤ 20 7 (4.32) 10 (3.73) 17 (3.95) 20–29 52 (32.10) 88 (32.84) 149 (34.65) 30–39 42 (29.93) 68 (25.37) 119 (27.67) 40–49 32 (19.75) 53 (19.78) 85 (19.77) 50–59 16 (9.88) 28 (10.45) 44 (10.23) ≥60 13 (8.02) 21 (7.84) 34 (7.91) 0.154 0.9 Sex Male 76 (46.91) 126 (47.01) 202 (46.98) Female 86 (53.09) 142 (52.99) 228 (53.02) 5.98 0.01 Marital status Single 61 (37.65) 101 (37.69) 162 (37.67) Married 77 (47.53) 127 (47.39) 204 (47.44) Divorced 0 (0.00) 2 (0.75) 2 (0.47) Widowed 24 (14.91) 38 (14.18) 62 (14.42) 1.24 0.74 Educational level Non-formal 16 (9.88) 26 (9.70) 42 (9.77) Primary 26 (16.05) 42 (15.67) 68 (15.81) Secondary 62 (38.27) 103 (38.43) 165 (38.37) Tertiary 58 (35.80) 97 (31.19) 42 (9.77) 0.017 0.9 Occupation Civil servants 42 (25.93) 70 (26.12) 112 (26.05) Self-employed 90 (55.56) 150 (55.97) 240 (5.58) Unemployed 20 (12.34) 33 (12.31) 53 (12.33) Others 10 (6.17) 15 (5.60) 25 (5.81) 0.067 0.9 62.3% 37.7% Inappropriate use Appropriate use Figure 1: Prevalence of inappropriate use of AED Table 2: Pattern of clinical presentations of non-urgent and urgent cases over different work shifts. Time period(Shifts) Appropriate n (%) Inappropriate n (%) Total n (%) χ2 p-value 8 am–3 pm 78 (29.10) 45 (27.78) 123 (28.60) 8.85 0.003 3 pm–8 pm 99 (36.94) 60 (37.04) 159 (36.98) 9.97 0.002 8 pm–8 am 91 (33.96) 57 (35.19) 148 (34.42) 7.81 0.005 Total 268 162 430 Note: χ2 = 0.107, p = 0.95, n = 430. 256 S Afr Fam Pract 2015; 57(4):253–258 The most common diagnoses based on ICPC chapters in this study were respiratory and endocrine/metabolic conditions. The occurrence of respiratory conditions as one of the most common problems among the inappropriately attending patients corrobo- rates with previous studies.15,18 High blood pressure and athero- sclerosis ranked first in China.19 This inappropriate utilisation of AED by these patients with respiratory diseases could be attribut- ed to the impact of emotions in patients suffering from respirato- ry diseases.20 Anxiety has also been associated with respiratory problems hence predisposing to urgent health-seeking behav- iour and visit to the AED inappropriately.21 The preponderance of patients with endocrine/metabolic conditions among the inap- propriate patients cannot be readily explained in this study. It is curious to note the absence of social and psychological problems among the diagnoses in this study. This corroborates with find- ings in previous studies.22 This could be explained by the fact that patients occasionally somatise their illness and express non-spe- cific complaints, which would be classified under other organic ICPC chapters and rubrics.22 The teaching of the biopsychosocial model of patient care in medical schools as against the present biomedical model will create awareness of the presence of the psychosocial aspect of ill health among medical practitioners and thereby improve the search for social and psychological prob- lems in patients. Polyuria and glycosuria, retroviral infection, URTI and hyperten- sion being the commonest diagnoses using the ICPC rubrics is a matter of serious concern in the environment of study. The change in lifestyle among the people resulting from affluence has made these problems very common. This implies that there should be intensification of health education to control them. The patients may be unwilling to leave their means of livelihood to attend to health matters especially if it is not very serious. Table 3: Clinical presentation of inappropriate cases by ICPC rubrics in AED Diagnoses Frequency n = 162 Percentage (%) Polyuria and glycosuria 16 9.88 Retroviral infection 15 9.26 URTI 15 9.26 Hypertension 15 9.26 Arthritis 13 8.02 Epigastric pain 13 8.02 Myalgia 11 6.79 Diabetic foot ulcer 10 6.17 Chronic renal failure 9 5.56 Constipation 9 5.56 Mild to moderate palor (weakness) 8 4.94 Hepatitis 7 4.32 Frequent stooling 7 4.32 Pneumonia 6 3.70 Ear pain 6 3.70 Chronic cough 5 3.09 Table 4: Problems diagnosed in AED by ICPC chapter Inappropriate (n = 162) Appropriate (n = 268) Total χ2(df = 1) p-value Gastrointestinal 35 (38.89) 55 (61.11) 90 (20.9) 4.4 0.035 Respiratory diseases 26 (83.87) 7 (22.58) 33 (7.7) 10.94 <0.001 Endocrine/metabolic 26 (57.78) 19 (42.22) 45 (10.5) 1.095 0.030 Musculoskeletal 23 (39.66) 35 (60.34) 58 (13.5) 2.48 0.12 Cardiac or vascular diseases 15 (62.5) 9 (37.50) 24 (5.6) 1.5 0.22 General & unspecified 15 (19.74) 61 (80.26) 76 (17.7) 27.84 <0.001 Genitourinary diseases 9 (37.50) 15 (62.50) 24 (5.6) 1.5 0.22 Blood 8 (66.67) 4 (33.33) 12 (2.9) 0.75 0.39 Central nervous 5 (10.64) 42 (89.36) 47 (10.9) 29.13 <0.001 Obstetric or contraception 0 (0.0) 21 (100.0) 21 (4.9) 19.05 <0.001 Table 5: Reasons for attending the AED inappropriately Reasons Frequency Percentage Self-referral for quick attention 75 46.3 Inadequate medication stock at Health Centre 67 41.4 Check-ups given at AED are more comprehensive 53 32.7 Doctors at AED are more skilful and efficient 47 29.0 Perception that the illness is serious and should be given due attention at AED 33 20.4 Ignorance of the hospital setting 28 17.3 Friends of hospital staff 20 12.3 Referred by doctors to specialist 19 11.7 Referred by churches and others 15 9.3 Proximity of AED to residence 10 6.2 Note: Total number of patients more than 162 due to multiple responses. Pattern of inappropriate cases presenting to the Accident and Emergency Department in a Nigeria Tertiary Hospital 257 Co-locating primary care services near or within AEDs will curb inappropriate utilisation of the services. This enables patients to self-select for urgent primary care rather than attending the AED as it becomes easier to choose which service they feel is most ap- propriate, given that they have made the decision to seek health care urgently. This has been reported in a study by van Uden et al., comparing attendance of the AED with a nearby primary care ser- vice and another one without such services, in which a difference of 35% was observed between them, with fewer patients attend- ing the former.30 We further recommend future multicentre research on this sub- ject which will span a longer duration. This will include a national- ly representative sample of patients attending A&E departments of all types to provide a further estimate of the percentage that inappropriately attend the AED and the reasons for such attend- ance. This study will provide generally accepted methods of curb- ing inappropriate use of AEDs. References 1. Lee A, Lau FL, Hazelett CB, et al. Utilisation of accident and emergency services by patients who could be managed by general practitioners. Hong Kong Med J. 2007;13(Suppl. 4):S28–31. 2. Green J, Dale J. Health education and the inappropriate use of ac- cident and emergency departments: the views of accident and emergency nurses. Health Educ J. 1990;49(4):157–61. http://dx.doi. org/10.1177/001789699004900402 3. Moskop JC, Sklar DP, Geiderman JM, et al. Emergency department crowding, part 1 — concept, causes, and moral consequences. Ann Emerg Med. 2009;53(5):605–11. http://dx.doi.org/10.1016/j. annemergmed.2008.09.019 4. Boeke AJP, van Randwijck-Jacobze ME, de Lange-Klerk EMS, et al. Effectiveness of GPs in accident and emergency departments. Br J Gen Pract. 2010;60(579):e378–84. http://dx.doi.org/10.3399/bjg- p10X532369 5. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126– 36. http://dx.doi.org/10.1016/j.annemergmed.2008.03.014 6. Carret ML, Fassa AC, Domingues MR. Inappropriate use of emergency services: a systematic review of prevalence and associated factors. Cad Saude Publica. 2009;25:7–28. http://dx.doi.org/10.1590/S0102- 311X2009000100002 7. Lang T, Davido A, Diakite B, et al. Non-urgent care in the hospital med- ical emergency department in France: how much and which health needs does it reflect? J Epidemiol Community Health. 1996;50:456–62. http://dx.doi.org/10.1136/jech.50.4.456 8. Lee A, Lau FL, Hazlett CB, et al. Measuring the inappropriate utili- zation of accident and emergency services? Int J Health Care Qual Assur Inc Leadersh Health Serv. 1999;12:287–92. http://dx.doi. org/10.1108/09526869910287558 9. Martin A, Martin C, Martin PB, et al. ‘Inappropriate’ attendance at an accident and emergency department by adults registered in local general practices: how is it related to their use of prima- ry care? J Health Serv Res Policy. 2002;7(3):160–5. http://dx.doi. org/10.1258/135581902760082463 10. Dale J, Green J, Reid F, et al. Primary care in the accident and emer- gency department: I. Prospective identification of patients. BMJ. 1995;311:423–426. 11. WHO. International Classification of Primary Care-2nd edition (ICPC-2). 2004 [cited 2014 Jan 04]. Available from: http://www.who.int/classifi- cation/icd/adaptations/icpc2/en/ 12. Siminski P, Bezzina AJ, Lago LP, et al. Primary care presentations at emergency departments: rates and reasons by age and sex. Aust Health Rev. 2008;32(4):700–9. http://dx.doi.org/10.1071/AH080700 13. Lega F, Mengoni A. Why non-urgent patients choose emergency over primary care services? Empirical evidence and managerial implica- tions. Health Policy. 2008;88(2–3): 326–38. http://dx.doi.org/10.1016/j. healthpol.2008.04.005 14. Bertakis KD, Azari R, Helms LJ, et al. Gender differences in the utiliza- tion of health care services. J Fam Pract. 2000;49(2):147–52. prevalence of URTI is not surprising considering the degree of at- mospheric pollution sequel to oil exploration, automobiles and electric power generators in the communities. The reasons for inappropriate presentation to the AED in this study are similar to findings by other researchers.23, 24 They include the need of quick attention, AED having better technical equip- ment, offering superior services, skillfulness of the doctors, to mention but a few. Patients need to be made aware that outpa- tient clinics are the first line clinics for minor cases where not many investigations will be required. Furthermore, patients need to be made aware that they can seek consultations the following day in outpatient clinics rather than going to the AED. Public edu- cation is therefore important. Strengths and limitations of the study The strength of this study lies inthe fact that this is the first time this type of study has been conducted in the AED of the Universi- ty of Port Harcourt Teaching Hospital. The results will provide a good insight into the level of inappropriate utilisation of its AED. There are several limitations with this study warranting caution in the interpretation of the findings. The study was conducted over a short period of time using a sample size in comparison to the overall annual attendances and hence the results may not pro- vide a true reflection of the reality. The study being performed in a single centre may not be generalisable to the other AEDS in dif- ferent parts of the country. Furthermore, some health problems could not be classified and were thus included among the gener- al and unspecified conditions. Conclusions and recommendations The level of inappropriate utilisation of the AED is very high in the University of Port Harcourt Teaching Hospital. This is caused by some misconceptions about the efficiency in the primary care system. Curbing inappropriate utilisation of AED can be achieved using a three-pronged approach. These include education, improvement of primary care accessibility and locating primary care clinics in the AED or close to the AED. The importance of education in the modification of health-seek- ing behaviour cannot be over emphasised. Michelin et al. in an evaluation of three educational interventions (health education, teaching patients how to use the health care system and provid- ing counselling in social/emotional issues) reported a significant a decrease in AED visits.25 Bird et al. similarly reported a 20.8% reduction in AED visits after educating patients in aspects of self-management.26 These reductions could be due to inappropri- ate users of the facilities seeking alternative sources of care such as primary health centres, community pharmacists and general practitioners. Considering the small population of physicians in Nigeria, educational intervention has to be the duty of all health care providers to avoid physicians being overwhelmed by the large number of patients. Interventions to enhance primary care accessibility include open- ing new centres and services, or expanding access to existing ser- vices.27 This will entail longer opening hours, increase in health care personnel and technical resources, deploying of primary care doctors to populations without this service and elimination of appointments.28 This was confirmed by Sjonell et al., who reported a 40% reduction in AED utilisation after a primary care centrewas established and medical doctors were employed.29 http://dx.doi.org/10.1177/001789699004900402 http://dx.doi.org/10.1177/001789699004900402 http://dx.doi.org/10.1016/j.annemergmed.2008.09.019 http://dx.doi.org/10.1016/j.annemergmed.2008.09.019 http://dx.doi.org/10.3399/bjgp10X532369 http://dx.doi.org/10.3399/bjgp10X532369 http://dx.doi.org/10.1016/j.annemergmed.2008.03.014 http://dx.doi.org/10.1590/S0102-311X2009000100002 http://dx.doi.org/10.1590/S0102-311X2009000100002 http://dx.doi.org/10.1136/jech.50.4.456 http://dx.doi.org/10.1136/jech.50.4.456 http://dx.doi.org/10.1108/09526869910287558 http://dx.doi.org/10.1108/09526869910287558 http://dx.doi.org/10.1258/135581902760082463 http://dx.doi.org/10.1258/135581902760082463 http://www.who.int/classification/icd/adaptations/icpc2/en/ http://www.who.int/classification/icd/adaptations/icpc2/en/ http://dx.doi.org/10.1071/AH080700 http://dx.doi.org/10.1016/j.healthpol.2008.04.005 http://dx.doi.org/10.1016/j.healthpol.2008.04.005 258 S Afr Fam Pract 2015; 57(4):253–258 24. Da PT, Awang Z, Ghani S, et al. Why do patients come to the Accident and Emergency Department, RIPAS Hospital? Brunei Int Med J. 2011; 7 (1):15–21. 25. Michelen W, Martinez J, Lee A, et al. Reducing frequent flyer emergen- cy department visits. J Health Care Poor Underserved. 2006;17:59–69. http://dx.doi.org/10.1353/hpu.2006.0010 26. Bird SR, Kurowski W, Dickman GK, et al. Integrated care facilitation for older patients with complex health care needs reduces hospital demand. Aust Health Rev. 2007;31:451–61. http://dx.doi.org/10.1071/ AH070451 27. Chalder M, Sharp D, Moore L, et al. Impact of NHS walk-in center on the workload of other local healthcare providers: time series analysis. BMJ. 2003;326:532–7. http://dx.doi.org/10.1136/bmj.326.7388.532 28. Oterino de la Fuente D, Baños Pino JF, Fernández Blanco V, et al. Does better access to primary care reduce utilization of hospital accident and emergency departments? A time-series analysis. Eur J Public Health. 2007;17:186–92. http://dx.doi.org/10.1093/eurpub/ckl085 29. Sjonell G. Effect of establishing a primary health care centre on the utilization of primary health care and other out-patient care in a Swed- ish urban area. Fam Pract. 1986;3:148–54. http://dx.doi.org/10.1093/ fampra/3.3.148 30. van Uden CJ, Winkens RA, Wesseling G, et al. The impact of a primary care physician cooperative on the caseload of an emergency depart- ment: the Maastricht integrated out-of-hours service. J Gen Intern Med. 2005;20: 612–7. http://dx.doi.org/10.1111/j.1525-1497.2005.0091.x 15. Wun YT, Wong TW, Tam W, et al. Patient characteristics of encounters in general practice. Hong Kong Pract. 2002;24: 59–65. 16. Travassos C, Viacava F, Pinheiro R, et al. Utilization of health care ser- vices in Brazil: gender, family characteristics, and social status. Rev Panam Salud Publica. 2002;11(5–6):365–73. http://dx.doi.org/10.1590/ S1020-49892002000500011 17. Soltani MS, Letaief M, Ben Salem K, et al. Motifs de contacts au niveau de première ligne dans le Sahel tunisien. Arch Public Health. 2002;60:125–40. 18. Dickinson JA, Chan CSY. Antibiotic use by practitioner in Hong Kong. Hong Kong Pract. 2002;24:282–91. 19. Wun YT, Lu XQ, Liang WN. The work by the developing primary care team in China: a survey in two cities. Fam Pract. 2000;17:10–15. http:// dx.doi.org/10.1093/fampra/17.1.10 20. Von Leopoldt A, Dahme B. The impact of emotions on symptom per- ception in patients with asthma and healthy controls. Psychophysiol- ogy. 2013;50(1):1–4. http://dx.doi.org/10.1111/psyp.2013.50.issue-1 21. Brenes GA. Anxiety and chronic obstructive pulmonary disease: prev- alence, impact, and treatment. Psychosom Med. 2003;65(6):963–70. http://dx.doi.org/10.1097/01.PSY.0000097339.75789.81 22. Pearson N, Jim OB, Huw T. Collecting morbidity data in general prac- tice: the Somerest morbidity project. BMJ. 1996;312:1517–20. http:// dx.doi.org/10.1136/bmj.312.7045.1517 23. Vazquez QB, Pardo MG, Fernandez CG, et al. Why do our patients go to hospital emergency departments? Atencion Primria. 2000;25:172–5. http://dx.doi.org/10.1016/S0212-6567(00)78482-4 Received: 25-07-2014 Accepted: 05-10-2014 http://dx.doi.org/10.1353/hpu.2006.0010 http://dx.doi.org/10.1353/hpu.2006.0010 http://dx.doi.org/10.1071/AH070451 http://dx.doi.org/10.1071/AH070451 http://dx.doi.org/10.1136/bmj.326.7388.532 http://dx.doi.org/10.1093/eurpub/ckl085 http://dx.doi.org/10.1093/fampra/3.3.148 http://dx.doi.org/10.1093/fampra/3.3.148 http://dx.doi.org/10.1111/j.1525-1497.2005.0091.x http://dx.doi.org/10.1590/S1020-49892002000500011 http://dx.doi.org/10.1590/S1020-49892002000500011 http://dx.doi.org/10.1093/fampra/17.1.10 http://dx.doi.org/10.1093/fampra/17.1.10 http://dx.doi.org/10.1111/psyp.2013.50.issue-1 http://dx.doi.org/10.1097/01.PSY.0000097339.75789.81 http://dx.doi.org/10.1097/01.PSY.0000097339.75789.81 http://dx.doi.org/10.1136/bmj.312.7045.1517 http://dx.doi.org/10.1136/bmj.312.7045.1517 http://dx.doi.org/10.1016/S0212-6567(00)78482-4 http://dx.doi.org/10.1016/S0212-6567(00)78482-4 Introduction Materials and methods Setting Sample size Sampling method Procedure Statistical analysis Results Discussion Strengths and limitations of the study Conclusions and recommendations References