Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme
Objectives To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda.Design Retrospective cohort analysis with multivariable logistic regression.Se...
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BMJ Publishing Group
2022-06-01
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| Series: | BMJ Open |
| Online Access: | https://bmjopen.bmj.com/content/12/6/e059859.full |
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| author | Rebecca Leff Brian Rice Bradley Dreifuss Heather Hammerstedt Mark Bisanzo Stacey Chamberlain Ashley Pickering Colleen Laurence Prisca Mary Kizito Steven Jonathan Kisingiri Charles Ndyamwijuka Serena Nakato Lema Felix Adriko |
| author_facet | Rebecca Leff Brian Rice Bradley Dreifuss Heather Hammerstedt Mark Bisanzo Stacey Chamberlain Ashley Pickering Colleen Laurence Prisca Mary Kizito Steven Jonathan Kisingiri Charles Ndyamwijuka Serena Nakato Lema Felix Adriko |
| collection | DOAJ |
| description | Objectives To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda.Design Retrospective cohort analysis with multivariable logistic regression.Setting Single rural Ugandan emergency unit.Participants All patients presenting for care from 2009 to 2019.Interventions Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: ‘Direct Supervision’ (2009–2010) emergency medicine physicians directly supervised all care; ‘Indirect Supervision’ (2010–2015) emergency medicine physicians were consulted as needed; ‘Independent Care’ (2015–2019) no emergency medicine physician supervision.Primary outcome measure Three-day mortality.Results 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts (‘Direct’ 3.8%, ‘Indirect’ 3.3%, ‘Independent’ 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals (‘Direct’ 32%, ‘Indirect’ 19%, ‘Independent’ 13%, p<0.001). After controlling for vital sign abnormalities, ‘Direct’ and ‘Indirect’ supervision were both significantly associated with reduced OR for mortality (‘Direct’: 0.57 (0.37 to 0.90), ‘Indirect’: 0.71 (0.55 to 0.92)) when compared with ‘Independent Care’. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals (‘Direct’: 0.44 (0.22 to 0.85), ‘Indirect’: 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals (‘Direct’: 0.81 (0.44 to 1.49), ‘Indirect’: 0.82 (0.58 to 1.16)).Conclusions Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages. |
| format | Article |
| id | doaj-art-f799ed0c41594a2ea244e19c0c68e61a |
| institution | Kabale University |
| issn | 2044-6055 |
| language | English |
| publishDate | 2022-06-01 |
| publisher | BMJ Publishing Group |
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| series | BMJ Open |
| spelling | doaj-art-f799ed0c41594a2ea244e19c0c68e61a2025-02-01T12:10:11ZengBMJ Publishing GroupBMJ Open2044-60552022-06-0112610.1136/bmjopen-2021-059859Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme 0Rebecca Leff1Brian Rice2Bradley DreifussHeather HammerstedtMark Bisanzo3Stacey ChamberlainAshley Pickering4Colleen Laurence5Prisca Mary Kizito6Steven Jonathan Kisingiri7Charles Ndyamwijuka8Serena Nakato9Lema Felix Adriko1011 Kenya National Bureau of Statistics, Nairobi, Nairobi, KenyaEmergency Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USAEmergency medicine, Stanford University, Stanford, California, USAEmergency Medicine, University of Vermont College of Medicine, Burlington, Vermont, USAEmergency Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USAEmergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USAEmergency Medicine, Mbarara University of Science and Technology, Mbarara, Mbarara, UgandaEmergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USAEmergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USAEmergency Medicine, Global Emergency Care, Shrewsbury, Massachusetts, USAEmergency Medicine, Karoli Lwanga Hospital, Rukungiri, Rukungiri, UgandaObjectives To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda.Design Retrospective cohort analysis with multivariable logistic regression.Setting Single rural Ugandan emergency unit.Participants All patients presenting for care from 2009 to 2019.Interventions Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: ‘Direct Supervision’ (2009–2010) emergency medicine physicians directly supervised all care; ‘Indirect Supervision’ (2010–2015) emergency medicine physicians were consulted as needed; ‘Independent Care’ (2015–2019) no emergency medicine physician supervision.Primary outcome measure Three-day mortality.Results 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts (‘Direct’ 3.8%, ‘Indirect’ 3.3%, ‘Independent’ 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals (‘Direct’ 32%, ‘Indirect’ 19%, ‘Independent’ 13%, p<0.001). After controlling for vital sign abnormalities, ‘Direct’ and ‘Indirect’ supervision were both significantly associated with reduced OR for mortality (‘Direct’: 0.57 (0.37 to 0.90), ‘Indirect’: 0.71 (0.55 to 0.92)) when compared with ‘Independent Care’. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals (‘Direct’: 0.44 (0.22 to 0.85), ‘Indirect’: 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals (‘Direct’: 0.81 (0.44 to 1.49), ‘Indirect’: 0.82 (0.58 to 1.16)).Conclusions Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.https://bmjopen.bmj.com/content/12/6/e059859.full |
| spellingShingle | Rebecca Leff Brian Rice Bradley Dreifuss Heather Hammerstedt Mark Bisanzo Stacey Chamberlain Ashley Pickering Colleen Laurence Prisca Mary Kizito Steven Jonathan Kisingiri Charles Ndyamwijuka Serena Nakato Lema Felix Adriko Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme BMJ Open |
| title | Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme |
| title_full | Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme |
| title_fullStr | Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme |
| title_full_unstemmed | Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme |
| title_short | Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme |
| title_sort | emergency medicine physician supervision and mortality among patients receiving care from non physician clinicians in a task sharing model of emergency care in rural uganda a retrospective analysis of a single centre training programme |
| url | https://bmjopen.bmj.com/content/12/6/e059859.full |
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