Exploring the treatment delay in the care of patients with ST-elevation myocardial infarction undergoing acute percutaneous coronary intervention: a cross-sectional study.

BACKGROUND: A short delay between diagnosis and treatment for patients diagnosed with ST-elevation myocardial infarction (STEMI) is vital to prevent cardiac damage and mortality. The objective of this study was to explore the treatment delay and associated factors in the management of patients diagnosed with STEMI going for percutaneous coronary intervention (PCI). METHODS: In a cross-sectional multicenter study, the treatment delay (time between first electrocardiogram and start of PCI procedure) of STEMI patients in seven PCI centers in the Netherlands was measured. Data were analyzed by means of multivariable generalized linear models, accounting for a non-normally distributed outcome and clustering of patients within centers. RESULTS: In total, 1017 patient charts were included. The majority of the patients (78.7%) were treated within the guideline recommended time target of 90 min. Overall, the median treatment delay was 64 min (interquartile range 47-82). A significantly prolonged delay was found among patients of whom their first electrocardiogram was performed at a general practitioner's practice (+23.9 min; 95% confidence interval 9.9-40.8) or in-hospital (+9.5 min; 95% confidence interval 2.5-17.3), patients requiring interhospital transfer (+14.6 min; 95% confidence interval 7.6-22.4) or presenting with acute heart failure on admission (+17.6 min; 95% confidence interval 7.9-28.7). CONCLUSIONS: Despite a short median delay between first electrocardiogram and PCI, the time targets are occasionally exceeded for patients diagnosed with STEMI. To further improve the process of care, PCI centers should focus on improving regional STEMI care networks, involving general practitioners, emergency departments and referring hospitals.

Understanding factors that influence the use of risk scoring instruments in the management of patients with unstable angina or non-ST-elevation myocardial infarction in the Netherlands: a qualitative study of health care practitioners' perceptions.

BACKGROUND: Cardiac risk scores estimate a patient's risk of future cardiac events or death. They are developed to inform treatment decisions of patients diagnosed with unstable angina or non-ST-elevation myocardial infarction. Despite recommending their use in guidelines and evidence of their prognostic value, they seem underused in practice. The purpose of the study was to gain insight in the motivation for implementing cardiac risk scores, and perceptions of health care practitioners towards the use of these instruments in clinical practice. METHODS: This qualitative study involved semi-structured interviews with 31 health care practitioners at 11 hospitals throughout the Netherlands. Participants were approached through purposive sampling to represent a broad range of participant- and hospital characteristics, and included cardiologists, medical residents, medical interns, nurse practitioners and an emergency physician. The Pettigrew and Whipp Framework for strategic change was used as a theoretical basis. Data were initially analysed through open coding to avoid forcing data into categories predetermined by the framework. RESULTS: Cardiac risk score use was dependent on several factors, including IT support, clinical relevance for daily practice, rotation of staff and workload. Both intrinsic and extrinsic drivers for implementation were identified. Reminders, feedback and IT solutions were strategies used to improve and sustain the use of these instruments. The scores were seen as valuable support systems in improving uniformity in treatment practices, educating interns, conducting research and quantifying a practitioner's own risk assessment. However, health care practitioners varied in their perceptions regarding the influence of cardiac risk scores on treatment decisions. CONCLUSIONS: Health care practitioners disagree on the value of cardiac risk scores for clinical practice. Practitioners driven by intrinsic motivations predominantly experienced benefits in policy-making, education and research. Practitioners who were forced to use cardiac risk scores were less likely to take into account the risk score in their treatment decisions. The results of this study can be used to develop strategies that stimulate or sustain cardiac risk score use in practice, while taking into account barriers that affect cardiac risk score use, and possibly reduce practice variation in the management of unstable angina and non-ST-elevation myocardial infarction patients.

Associations of the Emergency Severity Index triage categories with patients' vital signs at triage: a prospective observational study.

STUDY OBJECTIVE: Previous studies on the construct validity of the Emergency Severity Index (ESI) were focused on outcome measures which could not be obtained directly at triage. A study was conducted to the construct validity of the ESI by measuring the association between the ESI triage categories and patients' vital signs at triage. METHODS: A prospective observational study was conducted at an emergency department (ED) in the Netherlands. All patients who entered the ED between 20 July 2009 and 21 August 2009 were eligible for inclusion in the study. Patients' vital signs, triage category, age, gender, referrer and main complaint were registered. Vital signs were scored according to the Worthing Physiological Scoring System (WPSS) and the numerical pain rating scale. The data were analysed using ordinal logistic regression analyses. RESULTS: An association was found between ESI triage categories and patients' vital signs at triage. Patients in WPSS categories 'urgent' and 'alert' were more likely triaged into the urgent triage categories (ESI triage categories 1 and 2) than patients with normal WPSS scores. However, no associations were found between pain scores and ESI triage categories. CONCLUSION: This study supports the validity of the ESI as it showed that patients' vital signs are associated with the ESI triage categories. However, a revision of the ESI guidelines concerning pain assessments is necessary.

Pain assessments at triage with the Manchester triage system: a prospective observational study.

OBJECTIVE: Pain is one of the six general discriminators of the Manchester triage system (MTS). The frequency of pain assessments conducted at triage with the MTS, and patient, nurse and triage characteristics associated with pain assessments were studied. Also, nurses' reasons for not assessing pain at triage were studied. METHODS: The study consisted of two parts. In part 1, nurses from two emergency departments (ED) registered patient characteristics and the process of triage for every presenting patient during 1 week in May 2009. The characteristics of triage nurses were registered on a second form. In part 2 of the study, 13 nurses were interviewed about reasons for not assessing pain at triage. RESULTS: According to the MTS guidelines, pain assessments should have been conducted in 86.1% of the patient presentations. It was only assessed in 32.2% of these patients. Characteristics associated with conducting pain assessments were children under 12 years of age, patients referred by others than a general practitioner or ambulance service, intake of medication before an ED visit, experience of the nurse with the MTS and the duration of triage. Reasons for not assessing pain according to the guidelines included the thought of triage nurses that pain assessments result in overtriage. CONCLUSIONS: Pain assessments at triage are conducted infrequently because of insufficient education, conducting activities at triage that are not necessary for estimating urgency and a lack of clarity in the MTS guidelines. Changes in these areas are necessary to improve the reliability and validity of pain assessments and the MTS.

Handover Structure and Quality in the Acute Medical Assessment Unit: A Prospective Observational Study.

OBJECTIVES: Inadequate patient handovers are associated with the occurrence of medical errors. The objective of the present study was to explore the structure and quality of handovers in the acute medical assessment unit. METHODS: A prospective observational study was conducted in an academic hospital in the Netherlands. Handover structure was observed by ordering handover information according to the elements of the Situation, Background, Assessment, Recommendation, and Read back (SBAR-R) handover tool. Handover quality was measured by means of a questionnaire, i.e., the rating tool for handover quality, and by assessing situation awareness of the degree to which professionals after a handover agreed on the complexity of the patient's care needs. RESULTS: A total of 71 handovers were observed. In most handovers, different elements of the SBAR-R were used frequently (median, 7.5 elements; range, 2.0-15.0). On the quality of handovers, 109 respondents (44.1%) completed the questionnaire. On a 0-to-100 scale, median scores on information transfer were 67.9 (interquartile range [IQR],17.9), 75.0 (IQR, 25.0) on shared understanding, and 75.0 (IQR, 16.7) on working atmosphere. Agreement in situation awareness was 70.0%. CONCLUSIONS: Handovers in the acute medical assessment unit were poorly structured; however, the perceived quality of handovers was substantial. Implementing the SBAR-R may be an effective strategy to improve handover practice and situation awareness, although further study to its applicability in acute medical assessment units is necessary.

Adherence to Cardiac Practice Guidelines in the Management of Non-ST-Elevation Acute Coronary Syndromes: A Systematic Literature Review.

BACKGROUND: In the management of non-ST-elevation acute coronary syndrome (NSTACS) a gap between guideline-recommended care and actual practice has been reported. A systematic overview of the actual extent of this gap, its potential impact on patient-outcomes, and influential factors is lacking. OBJECTIVE: To examine the extent of guideline adherence, to study associations with the occurrence of adverse cardiac events, and to identify factors associated with guideline adherence. METHOD: Systematic literature review, for which PUBMED, EMBASE, CINAHL, and the Cochrane library were searched until March 2016. Further, a manual search was performed using reference lists of included studies. Two reviewers independently performed quality-assessment and data extraction of the eligible studies. RESULTS: Adherence rates varied widely within and between 45 eligible studies, ranging from less than 5.0 % to more than 95.0 % for recommendations on acute and discharge pharmacological treatment, 34.3 % - 93.0 % for risk stratification, and 16.0 % - 95.8 % for performing coronary angiography. Seven studies indicated that higher adherence rates were associated with lower mortality. Several patient-related (e.g. age, gender, co-morbidities) and organization-related (e.g. teaching hospital) factors influencing adherence were identified. CONCLUSION: This review showed wide variation in guideline adherence, with a substantial proportion of NST-ACS patients possibly not receiving guideline-recommended care. Consequently, lower adherence might be associated with a higher risk for poor prognosis. Future research should further investigate the complex nature of guideline adherence in NST-ACS, its impact on clinical care, and factors influencing adherence. This knowledge is essential to optimize clinical management of NSTACS patients and could guide future quality improvement initiatives.

Multicentre analysis of current ST-elevation myocardial infarction acute care pathways.

BACKGROUND: Rapid reperfusion with percutaneous coronary intervention (PCI) is vital for patients with ST segment elevation myocardial infarction (STEMI). However, the guideline-recommended time targets are regularly exceeded. The goal of this study was to gain insight into how Dutch PCI centres try to achieve these time targets by comparing their care processes with one another and with the European guideline-recommended process. In addition, accelerating factors perceived by care providers were identified. METHODS: In this multiple case study, interviews with STEMI care providers were conducted, transcribed and used to create process descriptions per centre. Analyses consisted of within-case and between-case analyses of the processes. Accelerating factors were identified by means of open and axial coding. RESULTS: In total, 28 interviews were conducted in six PCI centres. The centres differed from the guideline-recommended process on, for example, additional, unavoidable patient routings and monitoring delays, and from one another on the communication of diagnostic information (eg, transmitting all, only ambiguous or no ECGs) and catheterisation room preparation. These differences indicated diverging choices to maintain a balance between speed and diagnostic accuracy. Factors perceived by care providers as accelerating the process included trust in the tentative diagnosis, and avoiding unnecessary intercaregiver consultations. The combination of processes and accelerating factors were summarised in a model. CONCLUSIONS: Numerous differences in processes between PCI centres were identified. Several time-saving strategies were applied by PCI centres, however, in different configurations. To further improve the care for patients with STEMI, best practices can be shared between centres and countries.

Patient factors that influence clinicians' decision making in self-management support: A clinical vignette study.

BACKGROUND AND AIM: Self-management support is an integral part of current chronic care guidelines. The success of self-management interventions varies between individual patients, suggesting a need for tailored self-management support. Understanding the role of patient factors in the current decision making of health professionals can support future tailoring of self-management interventions. The aim of this study is to identify the relative importance of patient factors in health professionals' decision making regarding self-management support. METHOD: A factorial survey was presented to primary care physicians and nurses. The survey consisted of clinical vignettes (case descriptions), in which 11 patient factors were systematically varied. Each care provider received a set of 12 vignettes. For each vignette, they decided whether they would give this patient self-management support and whether they expected this support to be successful. The associations between respondent decisions and patient factors were explored using ordered logit regression. RESULTS: The survey was completed by 60 general practitioners and 80 nurses. Self-management support was unlikely to be provided in a third of the vignettes. The most important patient factor in the decision to provide self-management support as well as in the expectation that self-management support would be successful was motivation, followed by patient-provider relationship and illness perception. Other factors, such as depression or anxiety, education level, self-efficacy and social support, had a small impact on decisions. Disease, disease severity, knowledge of disease, and age were relatively unimportant factors. CONCLUSION: This is the first study to explore the relative importance of patient factors in decision making and the expectations regarding the provision of self-management support to chronic disease patients. By far, the most important factor considered was patient's motivation; unmotivated patients were less likely to receive self-management support. Future tailored interventions should incorporate strategies to enhance motivation in unmotivated patients. Furthermore, care providers should be better equipped to promote motivational change in their patients.

Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands.

OBJECTIVE: Cardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS. DESIGN: A web-based survey containing clinical vignettes. SETTING AND PARTICIPANTS: Registered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes 'without' a risk score present, while group 2 completed vignettes 'with' a risk score present. RESULTS: 129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores. CONCLUSIONS: When deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.

A cross-sectional multicentre study of cardiac risk score use in the management of unstable angina and non-ST-elevation myocardial infarction.

OBJECTIVES: Quantitative risk assessment in unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI), by using cardiac risk scores, is recommended in international guidelines. However, a gap between recommended care and actual practice exists, as these instruments seem underused in practice. The present study aimed to determine the extent of cardiac risk score use and to study factors associated with lower or higher cardiac risk score use. SETTING: 13 hospitals throughout the Netherlands. PARTICIPANTS: A retrospective chart review of 1788 charts of patients with UA and NSTEMI, discharged in 2012. PRIMARY AND SECONDARY OUTCOMES: The extent of cardiac risk score use reflected in a documented risk score outcome in the patient's chart. Factors associated with cardiac risk score use determined by generalised linear mixed models. RESULTS: In 57% (n=1019) of the charts, physicians documented the use of a cardiac risk score. Substantial variation between hospitals was observed (16.7-87%), although this variation could not be explained by the presence of on-site revascularisation facilities or a hospitals' teaching status. Obese patients (OR=1.49; CI 95%1.03 to 2.15) and former smokers (OR=1.56; CI 95%1.15 to 2.11) were more likely to have a cardiac risk score documented. Risk scores were less likely to be used among patients diagnosed with UA (OR=0.60; CI 95% 0.46 to 0.77), in-hospital resuscitation (OR=0.23; CI 95% 0.09 to 0.64), in-hospital heart failure (OR=0.46; CI 95% 0.27 to 0.76) or tachycardia (OR=0.45; CI 95% 0.26 to 0.75). CONCLUSIONS: Despite recommendations in cardiac guidelines, the use of cardiac risk scores has not been fully implemented in Dutch practice. A substantial number of patients did not have a cardiac risk score documented in their chart. Strategies to improve cardiac risk score use should pay special attention to patient groups in which risk scores were less often documented, as these patients may currently be undertreated.

Differences between pulmonologists, thoracic surgeons and radiation oncologists in deciding on the treatment of stage I non-small cell lung cancer: A binary choice experiment.

BACKGROUND AND PURPOSE: Surgery is the standard of care in stage I non-small cell lung cancer (NSCLC), but stereotactic ablative radiotherapy (SABR) is increasingly used to treat patients at high-risk for surgical complications. We studied which patient- and clinician-related characteristics influenced treatment recommendations. MATERIAL AND METHODS: A binary choice experiment with hypothetical cases was conducted. Cases varied on five patient-related characteristics: patient age, Chronic Obstructive Pulmonary Disease Global Initiative for Chronic Obstructive Lung Disease (COPD GOLD) score, Charlson co-morbidity index, World Health Organization performance status (WHO-PS) and patient treatment preference (surgery/SABR). Clinician characteristics were recorded. Responses were analyzed using generalized linear mixed models. RESULTS: 126 clinicians completed the survey. All patient-related characteristics, the clinician speciality, and whether clinicians considered outcomes of surgery comparable to SABR, significantly influenced treatment recommendations. Pulmonologists were most influenced by WHO-PS and comorbidity, whereas comorbidity and age had greatest influence on radiation oncologists and surgeons. Clinicians were less influenced by stated patient preference and COPD GOLD score. Limited consistency was observed in treatment recommendations. CONCLUSIONS: This study suggests that more efforts are needed to develop uniform approaches for making treatment recommendations, and also to incorporate patient preferences when making treatment decisions for stage I NSCLC.

Clinical decision-making of cardiologists regarding admission and treatment of patients with suspected unstable angina or non-ST-elevation myocardial infarction: protocol of a clinical vignette study.

INTRODUCTION: Cardiologists face the difficult task of rapidly distinguishing cardiac-related chest pain from other conditions, and to thoroughly consider whether invasive diagnostic procedures or treatments are indicated. The use of cardiac risk-scoring instruments has been recommended in international cardiac guidelines. However, it is unknown to what degree cardiac risk scores and other clinical information influence cardiologists' decision-making. This paper describes the development of a binary choice experiment using realistic descriptions of clinical cases. The study aims to determine the importance cardiologists put on different types of clinical information, including cardiac risk scores, when deciding on the management of patients with suspected unstable angina or non-ST-elevation myocardial infarction. METHODS AND ANALYSIS: Cardiologists were asked, in a nationwide survey, to weigh different clinical factors in decision-making regarding patient admission and treatment using realistic descriptions of patients in which specific characteristics are varied in a systematic way (eg, web-based clinical vignettes). These vignettes represent patients with suspected unstable angina or non-ST-elevation myocardial infarction. Associations between several clinical characteristics, with cardiologists' management decisions, will be analysed using generalised linear mixed models. ETHICS AND DISSEMINATION: The study has received ethics approval and informed consent will be obtained from all participating cardiologists. The results of the study will provide insight into the relative importance of cardiac risk scores and other clinical information in cardiac decision-making. Further, the results indicate cardiologists' adherence to the European Society of Cardiology guideline recommendations. In addition, the detailed description of the method of vignette development applied in this study could assist other researchers or clinicians in creating future choice experiments.

Dutch General Practitioners' weight management policy for overweight and obese patients.

BACKGROUND: General practitioners (GPs) can play an important role in both the prevention and management of overweight and obesity. Current general practice guidelines in the Netherlands allow room for GPs to execute their own weight management policy. OBJECTIVE: To examine GPs' current weight management policy and the factors associated with this policy. METHODS: 800 Dutch GPs were asked to complete a questionnaire in December 2012. The questionnaire items were based on the Dutch Obesity Standard for GPs. The data were analyzed by means of descriptive statistics and multiple linear regression analyses in 2013. RESULTS: In total, 307 GPs (39.0%) responded. Most respondents (82.9%) considered weight management as part of their responsibility for providing care. GPs aged <48 years discussed weight less frequent. Next, weight is less frequently discussed with patients without weight-related comorbidities or with moderately overweight patients compared to obese patients. On average, 47.7% of the GPs reported to refer obese patients to a weight management professional, preferably a dietitian (98.3%). GPs with a BMI ≥ 25 kg/m(2) were less likely to refer obese patients. In addition, GPs who had frequent contact with a dietitian were more likely to refer obese patients. CONCLUSIONS: In the context of General Practice and preventive medicine, GPs' discussion of weight and the variety of obesity-determinants with their moderately overweight patients deserves more attention, especially from younger GPs. Strengthening interdisciplinary collaboration between GPs and dietitians could increase the referral percentage for dietary treatment.

Societal preferences for standard health insurance coverage in the Netherlands: a cross-sectional study.

INTRODUCTION: Cost-effectiveness is an important criterion in the decision to cover interventions in health insurance packages. One of the outcome measures, the quality-adjusted life year, has been criticised on its assumptions and implications concerning life expectancy and quality of life. Several studies have been conducted that measured societal preferences concerning healthcare rationing decisions. These studies mainly focused on one attribute. To adjust quality-adjusted life year maximisation in accordance with societal preferences, the relative importance of attributes should be studied. The present study aims to measure the relative importance of age, gender, socioeconomic status, pre-intervention health state, treatment effect, chance of treatment success and number of people in need of the intervention. A secondary objective is to compare the validity of the willingness to pay method with the validity of a relatively new preference elicitation method, best-worst scaling. METHODS AND ANALYSIS: A representative sample of 2000 Dutch citizens, over 18 years of age, are recruited to complete a web-based survey containing treatment scenarios. The scenarios present different levels of attributes. Respondents are asked to select one of the four scenarios that they prefer to be covered by the Dutch standard health insurance package and one that they prefer not to be covered. They are also asked to indicate how much they are willing to pay for each treatment scenario. At the end of the survey, respondents are asked to rate every attribute on a 1-10 scale. Two versions of the questionnaire are developed which differ on the framing, that is, treatments can be added to or removed from the insurance package. The data will be analysed by means of sequential conditional logit analysis (best-worst scaling) and analysis of variance (willingness to pay). ETHICS AND DISSEMINATION: The protocol is reviewed and approved by the medical ethical committee of the University Medical Center Leiden.

Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study.

OBJECTIVES: It is difficult to compare the reliability of triage systems with the kappa statistic. In this article, a method for comparing triage systems was developed and applied to previously conducted triage reliability studies. STUDY DESIGN AND SETTING: From simulations with theoretical distributions, the minimum, normal, and maximum weighted kappa for 3- to 5-level triage systems were computed. To compare the reliability of triage systems in previously conducted triage reliability studies, the normal kappa was calculated. Furthermore, the reported quadratically weighted kappas were compared with the minimum, normal, and maximum weighted kappa to characterize the degree and direction of skewness of the data. RESULTS: The normal kappa was higher in 3-level triage systems (median: κ=0.84) compared with 4-level (median: κ=0.37) and 5-level (median: κ=0.57) systems. In 3-level triage systems, the percentages observed agreement were unequally distributed, which resulted in small quadratically weighted kappas. In 4- and 5-level systems, the percentages observed agreement were more equally distributed compared with 3-level systems, which resulted in higher quadratically weighted kappa values. CONCLUSION: When comparing triage systems with different numbers of categories, one should report both the normal and quadratically weighted kappa. Calculating normal kappas from previously conducted triage reliability studies revealed substantial theoretical differences in interrater reliability of triage systems than previously reported.

An observational study of patients triaged in category 5 of the Emergency Severity Index.

OBJECTIVE: Patients triaged in category 5 of the Emergency Severity Index (ESI) do not need any resources before discharge from the emergency department (ED). We studied the characteristics of these patients and focused on those who were admitted or sent to the outpatient department after their ED visit. METHODS: A retrospective observational study was conducted on 117 740 patient presentations. Patients were included in the study when they were triaged with the ESI and presented to one of the two EDs under study between 1 September 2004 and 1 June 2006. RESULTS: Overall, 22.2% of the patients were triaged in ESI 5. Patients aged less than 40 years, women, and self-referred patients were most likely triaged in ESI 5, as well as patients presenting with complaints such as 'checkup appointments at the ED' and 'complaints of the skin'. Patients triaged in ESI 5 who were admitted or sent to the outpatient department were most likely elderly (aged above 65 years) and referred patients. They were also more likely to present with complaints such as 'postoperative complications, wound care problems, and plaster problems' and 'complaints of the genitourinary system'. CONCLUSION: Although younger patients and women were more likely triaged in ESI 5, patients within this category who were admitted or sent to the outpatient department were more likely elderly and referred patients. Being admitted or sent to the outpatient department and triaged in ESI 5 indicates undertriage. Revision of the system is required to properly account for these patient groups.

Adjusting weighted kappa for severity of mistriage decreases reported reliability of emergency department triage systems: a comparative study.

OBJECTIVE: Mistriage can have serious consequences for patients with urgent complaints. We therefore reviewed the assessment of triage-reliability, and propose an alternative weighted kappa that accounts for severity of mistriage. STUDY DESIGN AND SETTING: A systematic literature search was performed in three online databases and a search engine. An alternative kappa weighting scheme was developed (triage-weighted kappa), and kappas of previous conducted reliability studies were recalculated. RESULTS: Kappa is the most frequently used statistic in triage-reliability studies (n=33). More than half of the studies did not report the type of kappa that was used. Linear and quadratically weighted kappa values do not reflect the seriousness of mistriage. Several studies reported almost perfect agreement, whereas percentages of mistriage ranged between 11.1% and 43.4%. In all studies, triage-weighted kappa was lower than reported kappas with a mean difference of 0.17 (range: 0.04-0.32). CONCLUSION: No existing studies on reliability of triage systems account for mistriage. Using triage-weighted kappa, which reflects severity of mistriage, shows that the reliability of triage systems is lower than reported.