"background": "Emergency care systems in Kenya face significant challenges, yet a comprehensive methodological evaluation of the analytical approaches used to measure their impact on clinical outcomes is lacking. Understanding the rigour and limitations of existing evidence is crucial for informing policy and practice. ", "purpose and objectives": "This systematic review aims to critically appraise the application of multilevel regression analyses in studies evaluating clinical outcomes within Kenyan emergency care units, assessing methodological strengths, limitations, and reporting standards. ", "methodology": "A systematic search of multiple electronic databases was conducted for peer-reviewed studies employing multilevel models to analyse clinical outcome data. Studies were screened, selected, and their methodological quality assessed using a predefined tool. The core statistical model evaluated was of the form y{ij = \0 + \1xij + uj + eij, where u₉ represents the random intercept for hospital j. ", "findings": "Of the 27 included studies, a predominant methodological weakness was the failure to account for clustering in the data, with only 41% appropriately specifying random effects. Where used, multilevel models revealed that facility-level factors, such as staffing ratios, explained a significant proportion of variance in mortality outcomes (ICC = 0. 18, 95% CI: 0. 12, 0. 24). ", "conclusion": "The application of multilevel regression in this context is inconsistent and often methodologically flawed, limiting the reliability of evidence for system-level interventions. There is a pressing need for improved analytical rigour. ", "recommendations": "Future research must prioritise proper multilevel modelling techniques to generate robust, generalisable evidence. Capacity building in advanced statistical methods for local researchers and the development of national emergency care registries are essential. ", "key words": "emergency medical services, health systems research, hierarchical linear models, sub-Saharan Africa, clinical epidemiology", "contribution statement": "This review provides the first methodological synthesis of multilevel
Oluoch et al. (Fri,) studied this question.