Abstract

BackgroundMany health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.MethodsA patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.ResultsFour tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.ConclusionsThe cost-effective triage tool depends on the English decision maker’s MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

Highlights

  • Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement

  • There is a definition of severe injuries that defines severe injuries as those injuries that would benefit from care that is only available at MTCs in a US setting [7]

  • All incremental cost-effectiveness ratio (ICER) are in excess of £30,000 per quality adjusted life years (QALYs) gained, they are above the upper limit of the ICER that National Institute for Health and Care Excellence (NICE) would consider acceptable, meaning that the cost-effective strategy is the least sensitive triage tool [9]

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Summary

Introduction

Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. In MTC systems if patients are suspected to be severely injured paramedics will bypass local hospitals, if these are closer than the MTC, and the MTC will be prealerted to allow activation of a specialist major trauma team for resuscitation and initial management. There is a definition of severe injuries that defines severe injuries as those injuries that would benefit from care that is only available at MTCs in a US setting [7] As this is not yet widely used in the literature to estimate the benefits of MTC care, we use the ISS definition of MTC need

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