• Deepika Mohan, Amber E Barnato, Matthew R Rosengart, Derek C Angus, and Kenneth J Smith.
• The CRISMA Laboratory, Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA. mohand@upmc.edu
• Am J Manag Care. 2012 Mar 1; 18 (3): e91-e100.

ObjectivesTo identify the optimal target of a future intervention to improve physician decision making in trauma triage.Study DesignComparison of incremental costeffectiveness ratios (ICERs) of current practice with hypothetical interventions targeting either physicians' decisional thresholds (attitudes toward transferring patients to trauma centers) or perceptual sensitivity (ability to identify patients who meet transfer guidelines).MethodsTaking the societal perspective, we constructed a Markov decision model, drawing estimates of triage patterns, mortality, utilities, and costs from the literature. We assumed that an intervention to change the decisional threshold would reduce undertriage but also increase overtriage more than an intervention to change perceptual sensitivity. We performed a series of 1-way sensitivity analyses and studied the most influential variables in a Monte Carlo simulation.ResultsThe ICER of an intervention to change perceptual sensitivity was $62,799 per qualityadjusted life-year (QALY) gained compared with current practice. The ICER of an intervention to change the decisional threshold was $104,975/ QALY gained compared with an intervention to change perceptual sensitivity. These findings were most sensitive to the relative cost of hospitalizing patients with moderate to severe injuries and their relative risk of dying at non-trauma centers. In probabilistic sensitivity analyses, at a willingness-to-pay threshold of $100,000/QALY gained, there was a 62% likelihood that an intervention to change perceptual sensitivity was the most cost-effective alternative.ConclusionsEven a minor investment in changing decision making in trauma triage could greatly improve quality of care. The optimal intervention depends on the characteristics of the individual trauma systems.

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