title: Mortality in Children Under Five Receiving Nonphysician Clinician Emergency Care in Uganda.
abstract: BACKGROUND
  A nonphysician clinician (NPC) training program was started in Uganda in 2009. NPC care was initially supervised by a physician and subsequent care was independent. The mortality of children under 5 (U5) was analyzed to evaluate the impact of transitioning NPC care from physician-supervised to independent care.
  
  
  METHODS
  A retrospective review was performed of a quality assurance database including 3-day follow-up for all patients presenting to the emergency department (ED). Mortality rates were calculated and χ(2) tests used for significance of proportions. Multiple logistic regression was used to assess independent predictors of mortality.
  
  
  RESULTS
  Overall, 68.8% of 4985 U5 patients were admitted and 28.6% were "severely ill." The overall mortality was significantly lower in physician-supervised versus independent NPC care (2.90% vs 5.04%, P = .05). No significant mortality difference was seen between supervised and unsupervised care (2.17% vs 3.01%, P = .43) for the majority of patients that were not severely ill. Severely ill patients analyzed separately showed a significant mortality difference (4.07% vs 10.3%, P = .01). Logistic regression revealed physician supervision significantly reduced mortality for patients overall (odds ratio = 0.52, P = .03), but not for nonseverely ill patients analyzed separately (odds ratio = 0.73, P = .47).
  
  
  CONCLUSIONS
  Though physician supervision reduced mortality for the severely ill subset of patients, physicians are not available full-time in most EDs in Sub-Saharan Africa. Training NPCs in emergency care produced noninferior mortality outcomes for unsupervised NPC care compared with physician-supervised NPC care for the majority of U5 patients.
authors.affiliation: Department of Emergency Medicine, New York University School of Medicine, New York, New York; brian.rice@nyumc.org.
authors.forename: Brian
authors.initials: B
authors.lastname: Rice
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts;
authors.forename: Usha
authors.initials: U
authors.lastname: Periyanayagam
authors.affiliation: Department of Emergency Medicine, University of Illinois-Chicago, Chicago, Illinois;
authors.forename: Stacey
authors.initials: S
authors.lastname: Chamberlain
authors.affiliation: Department of Emergency Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona;
authors.forename: Bradley
authors.initials: B
authors.lastname: Dreifuss
authors.affiliation: Department of Emergency Medicine, Idaho Emergency Physicians, Boise, Idaho;
authors.forename: Heather
authors.initials: H
authors.lastname: Hammerstedt
authors.affiliation: Department of Emergency Medicine, Maine Medical Center, Portland, Maine;
authors.forename: Sara
authors.initials: S
authors.lastname: Nelson
authors.affiliation: Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda; and.
authors.forename: Samuel
authors.initials: S
authors.lastname: Maling
authors.affiliation: Department of Emergency Medicine, University of Massachusetts, Worchester, Massachusetts.
authors.forename: Mark
authors.initials: M
authors.lastname: Bisanzo
mesh_terms: D046688:Child Mortality / Q000639:trends; D002675:Child, Preschool; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D004632:Emergency Medical Services / Q000379:methods*; D004638:Emergency Treatment / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D008297:Male; D017063:Outcome Assessment, Health Care; D010820:Physicians; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014454:Uganda / Q000453:epidemiology