Mortality Outcomes in Task-Sharing for Emergency Care: Impact of Emergency Physician Supervision on Non-Physician Emergency Care in Rural Uganda

Abstract

Introduction Emergency care (EC) capacity is limited by physician shortages in low- and middle-income countries like Uganda. Task-sharing (delegating tasks to more narrowly trained cadres) including EC nonphysician clinicians (NPCs) is a proposed solution. However, little data exists to guide emergency medicine (EM) physician supervision of NPCs. The study objective was to assess the mortality impact of decreasing EM physician supervision of EC NPCs. Methods Retrospective analysis of prospectively collected data from an EC NPC training program in rural Uganda included three cohorts: Direct (2009-2010): EM physicians supervised all NPC care; Indirect (2010-2015): NPCs consulted EM physicians on an ad hoc basis; Independent (2015-2019): NPC care without EM physician supervision. Multivariable logistic regression analysis of three-day mortality included demographics, vital signs, co-morbidities and supervision. Sensitivity analysis stratified patients by numbers of abnormal vital signs. Results Overall, 38,344 ED visits met inclusion criteria. From the Direct to the Unsupervised period patients with greater than or equal to 3 abnormal vitals (25.2% to 10.2%, p<0.001) and overall mortality (3.8% to 2.7%, p<0.001) decreased significantly. Indirect and Independent supervision were independently associated with increased mortality compared to Direct supervision (Indirect Odds Ratio (OR)=1.49 [95%CI 1.07 - 2.09], Independent OR=1.76 [95%CI 1.09 - 2.86]). The 86.2% of patients with zero, one or two abnormal vitals had similar mortality across cohorts, but the 13.8% of patients with greater than or equal to abnormal vitals had significantly reduced mortality with Direct supervision (Indirect OR=1.75 [95%CI 1.08 - 2.85], Independent (OR=2.14 [95%CI 1.05 - 4.34]). Conclusion Direct EM physician supervision of NPC care significantly reduced overall mortality as the highest risk ~10% of patients had nearly 50% reduction in mortality. However, for the other ~90% of ED visits, independent EC NPC care had similar mortality outcomes as directly supervised care, suggesting a synergistic model could address current staffing shortages limiting EC access and quality.