The Transaction Costs of Risk Management vs. Speculation in an Electronic Trading Environment

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. This study’s 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 ≥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 ≥3 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. SUMMARY BOX What is already known? Physician shortages and lack of specialty training limit implementation of emergency care and associated reductions in mortality in low- and middle-income countries (LMIC) such as Uganda. Task-sharing, often to non-physician clinicians, is proposed as a solution however data to support safe, effective training and physician supervision protocols is limited. What are the new findings? The highest risk 10% of emergency care patients have approximately a 50% reduction in mortality when non-physician clinicians are directly supervised by emergency medicine physicians. For most emergency care patients (the lowest risk 90%) independent emergency care by non-physician clinicians provides similar morality outcomes to direct supervision by an emergency medicine physician. What do the new findings imply? Training of both emergency care physicians and non-physician clinicians is essential, as physicians provide improved mortality outcomes, especially for the critically ill, and non-physician clinicians will help address lack of trained and available emergency care providers in a timely, cost-effective manner. Physician supervision of all emergency care is the penultimate goal, however non-physician clinicians can be trained to provide comparable morality outcomes for the vast majority of patients when practicing independently. Triage protocols are needed to identify high-risk emergency care patients, such as those with 3 or more abnormal vital signs, for early involvement of an emergency physician either directly, or through supervision of a non-physician clinician.

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