The Triage Capability of Laypersons: Retrospective Exploratory Analysis

Abstract

Background: Although medical decision-making may be thought of as a task involving health professionals, many decisions, including critical health-related decisions are made by laypersons alone. Specifically, as the first step to most care episodes, it is the patient who determines whether and where to seek health care (triage). Overcautious self-assessments (ie, overtriaging) may lead to overutilization of health care facilities and overcrowded emergency departments, whereas imprudent decisions (ie, undertriaging) constitute a risk to the patient's health. Recently, patient-facing decision support systems, commonly known as symptom checkers, have been developed to assist laypersons in these decisions.

Objective: The purpose of this study is to identify factors influencing laypersons' ability to self-triage and their risk averseness in self-triage decisions.

Methods: We analyzed publicly available data on 91 laypersons appraising 45 short fictitious patient descriptions (case vignettes; N=4095 appraisals). Using signal detection theory and descriptive and inferential statistics, we explored whether the type of medical decision laypersons face, their confidence in their decision, and sociodemographic factors influence their triage accuracy and the type of errors they make. We distinguished between 2 decisions: whether emergency care was required (decision 1) and whether self-care was sufficient (decision 2).

Results: The accuracy of detecting emergencies (decision 1) was higher (mean 82.2%, SD 5.9%) than that of deciding whether any type of medical care is required (decision 2, mean 75.9%, SD 5.25%; t_>90=8.4; P<.001; Cohen d=0.9). Sensitivity for decision 1 was lower (mean 67.5%, SD 16.4%) than its specificity (mean 89.6%, SD 8.6%) whereas sensitivity for decision 2 was higher (mean 90.5%, SD 8.3%) than its specificity (mean 46.7%, SD 15.95%). Female participants were more risk averse and overtriaged more often than male participants, but age and level of education showed no association with participants' risk averseness. Participants' triage accuracy was higher when they were certain about their appraisal (2114/3381, 62.5%) than when being uncertain (378/714, 52.9%). However, most errors occurred when participants were certain of their decision (1267/1603, 79%). Participants were more commonly certain of their overtriage errors (mean 80.9%, SD 23.8%) than their undertriage errors (mean 72.5%, SD 30.9%; t_>89=3.7; P<.001; d=0.39).

Conclusions: Our study suggests that laypersons are overcautious in deciding whether they require medical care at all, but they miss identifying a considerable portion of emergencies. Our results further indicate that women are more risk averse than men in both types of decisions. Layperson participants made most triage errors when they were certain of their own appraisal. Thus, they might not follow or even seek advice (eg, from symptom checkers) in most instances where advice would be useful.

Keywords: accuracy; care; care navigation; decision; decision support; digital health; emergency; error; female; health professional; male; medical; patient; patient-centered care; self-assessment; self-triage; sensitivity; support; symptom checker; triage; urgency assessment.

Figure 1

Accuracy, sensitivity, and specificity for 2 binary triage decisions by participants’ gender.

Figure 2

Risk averseness by age.

Figure 3

Risk averseness by education.

Figure 4

Risk averseness by gender.