A Methodological Evaluation of Emergency Care Systems in Rwanda: A Multilevel Regression Analysis of Clinical Outcomes

"background": "Emergency care systems in low-resource settings are critical for reducing preventable mortality, yet robust methodological frameworks for evaluating their clinical performance are lacking. This gap impedes the development of evidence-based improvements in service delivery and patient outcomes. ", "purpose and objectives": "This case study aims to methodologically evaluate the performance of hospital-based emergency care units by developing and applying a multilevel regression model to analyse clinical outcomes. The objective is to quantify the influence of system-level factors on patient survival. ", "methodology": "A retrospective cohort analysis was conducted using linked clinical and administrative data from a national sample of emergency units. The primary outcome was 48-hour survival. A three-level hierarchical logistic regression model was specified: (p{ijk) = \0 + \ Xijk + ujk + vₖ, where patients (i) are nested within shifts (j) and hospitals (k). Uncertainty was quantified using 95% confidence intervals derived from robust standard errors. ", "findings": "The analysis identified a significant association between the presence of a dedicated triage officer and improved 48-hour survival (adjusted odds ratio 1. 42, 95% CI 1. 15 to 1. 76). System-level factors, including shift-level staffing ratios, accounted for approximately 18% of the variance in patient outcomes, highlighting their substantial influence. ", "conclusion": "The methodological approach demonstrates that multilevel modelling is a powerful tool for disentangling complex, nested influences on clinical outcomes in emergency care systems. It moves beyond patient-level analysis to quantify modifiable system characteristics. ", "recommendations": "Routine health information systems should be structured to capture shift-level and facility-level operational data. Future evaluations of emergency care interventions should employ multilevel analytical techniques to accurately assess their impact and inform resource allocation. ", "key words": "health systems evaluation, emergency medical services, hierarchical modelling, clinical outcomes, low-resource settings", "contribution statement": "This study