Introduction: Diagnostic uncertainty significantly impacts patient safety in emergency medicine, leading to missed diagnoses and severe harm. Current predictive models primarily emphasize diagnostic likelihood without explicitly addressing potential clinical harm from errors. We propose Triage and Risk Assessment via Cost Estimation (TRACE), a machine-learning framework that incorporates expected-value calculations, defined as the probability-weighted estimate of clinical harm, and patient similarity metrics to address both diagnostic accuracy and risk assessment.
\nMethods: Using the Medical Information Mart for Intensive Care IV - Emergency Department dataset, we developed TRACE, comprising two modules: the expected value-powered triage index (TRACE-T), which calculates expected patient acuity from vital signs and chief complaints, and the patient similarity diagnosis engine (TRACE-Dx), which predicts diagnoses by identifying historically similar patients and weighing their outcomes by clinical harm. We assessed TRACE-T’s predictive performance, our primary outcome, using decision trees, random forests, and Lasso (least absolute shrinkage and selection operator) regression. The TRACE-Dx predictions, our secondary outcome, were evaluated through string matching (comparing diagnostic text) and sentence embedding similarity (comparing diagnostic phrases).
\nResults: Our final analysis included a total of 2,501 patients from the dataset, due to requirements for diagnosis-string cleaning and computational demands of similarity calculations. Within this subset, TRACE-T significantly improved triage prediction accuracy, with the random forest classifier’s accuracy increasing from 0.605 to 0.705 (P = .04) and demonstrating a notable reduction in root mean square error from 0.635 to 0.541 (P < .001). The decision tree model improved from 0.467 to 0.593 (P = .78) but did not reach statistical significance. The TRACE-Dx generated five expected value-ranked predicted diagnoses per encounter (12,505 predictions across 2,501 patients) and achieved average sentence embedding and string match similarities of 93.3% (95% CI, 92.7-94.0%) and 92.5% (95% CI, 90.7-94.3%), respectively, indicating strong alignment with actual outcomes.
\nConclusion: Expected value-based clinical harm modeling with patient similarity scoring enhances triage accuracy and diagnostic prediction in emergency care. Triage and Risk Assessment via Cost Estimation provides interpretable, actionable insights that could be incorporated into real-time clinical workflows as decision-support tools to reduce diagnostic uncertainty and improve patient outcomes.
","language":"eng","license":{"name":"Creative Commons Attribution 4.0","short_name":"CC BY 4.0","text":"Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.","url":"https://creativecommons.org/licenses/by/4.0"},"keywords":[],"section":"Medical Decision Making","is_remote":true,"remote_url":"https://escholarship.org/uc/item/2bq7k0s8","frozenauthors":[{"first_name":"Kian","middle_name":"D.","last_name":"Samadian","name_suffix":"","institution":"Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts","department":""},{"first_name":"Paul","middle_name":"","last_name":"Chong","name_suffix":"","institution":"Walter Reed National Military Medical Center, Department of Ophthalmology, Bethesda, Maryland","department":""},{"first_name":"Boyu","middle_name":"","last_name":"Peng","name_suffix":"","institution":"Massachusetts General Institute of Health Professions, Boston, Massachusetts","department":""},{"first_name":"Ahmad","middle_name":"","last_name":"Hassan","name_suffix":"","institution":"Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts","department":""},{"first_name":"Kevin","middle_name":"","last_name":"Shannon","name_suffix":"","institution":"University of Virginia School of Medicine, Charlottesville, Virigina","department":""},{"first_name":"Adriana","middle_name":"","last_name":"Coleska","name_suffix":"","institution":"Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts","department":""},{"first_name":"Abdel","middle_name":"","last_name":"Badih el Ariss","name_suffix":"","institution":"Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts","department":""},{"first_name":"Norawit","middle_name":"","last_name":"Kijpaisalratana","name_suffix":"","institution":"Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts","department":""},{"first_name":"Pedram","middle_name":"","last_name":"Safari","name_suffix":"","institution":"Massachusetts General Institute of Health Professions, Boston, Massachusetts","department":""},{"first_name":"Emma","middle_name":"","last_name":"Chua","name_suffix":"","institution":"Pasadena City College, Pasadena, California","department":""},{"first_name":"Daerin","middle_name":"","last_name":"Hwang","name_suffix":"","institution":"Williams College, Williamstown, Massachusetts","department":""},{"first_name":"Shuhan","middle_name":"","last_name":"He","name_suffix":"","institution":"Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts","department":""}],"date_submitted":"2025-07-29T15:10:56.377000Z","date_accepted":"2025-12-10T20:37:38.279000Z","date_published":"2026-02-27T16:31:00Z","render_galley":null,"galleys":[{"label":"PDF","type":"pdf","path":"https://journalpub.escholarship.org/westjem/article/50511/galley/49072/download/"}]}