In patients with burns an early accurate diagnosis of burn depth is essential to determine the most appropriate treatment. Monstrey et al. recently reviewed all current modalities to diagnose burn depth. Bedside clinical examination is the most widely used and least expensive method for burn depth assessment. This technique is effective when diagnosing burns at the extreme end of the spectrum: superficial or full thickness. In partial thickness burns, however, clinical examination is not very accurate. Clinical burn depth assessment is accurate in about 2/3 of the cases, the most reported error is overestimation of depth .
Overestimation of burn depth can lead to unnecessary excision and grafting [2, 3]. On the other hand, underestimation of burn depth may lead to an unnecessary delay in surgery, with a longer length of hospital stay and higher hospital costs as a consequence [4, 5]. In burn care, traditionally classified as expensive care, there is a growing interest in costs and cost control [6, 7]. In order to provide effective and cost-effective burn care, there is a need for an accurate method for burn depth estimation.
Laser Doppler imaging (LDI) is the only technique that has been shown to accurately predict wound depth with a large weight of evidence . Laser Doppler imaging is based on the Doppler principle. Laser light that is directed at moving blood cells in sampled tissue exhibits a frequency change that is proportional to the amount of perfusion in the tissue. Laser Doppler imaging combines the advantages of laser Doppler and scanning techniques: the whole burn can be sampled and no direct contact with the burn surface is necessary . In daily practice, LDI will be used in combination with standard clinical assessment , as a so-called add-on test .
Several prospective studies on the diagnostic accuracy of laser Doppler imaging have demonstrated an accuracy varying between 95-100% [3, 8, 10–12]. Timing of LDI is important: only scanning between 48 hours and 5 days results in a high accuracy (>95%) [8, 11, 13, 14].
To decide whether a new diagnostic strategy, like LDI, should be implemented, assessment of diagnostic accuracy should be followed by assessment of diagnostic and therapeutic impact, effectiveness and cost-effectiveness of the new technology [9, 15].
The literature on the accuracy of LDI in burn depth assessment is convincing. However, most studies only report on the accuracy of this technique. The diagnostic and therapeutic impact of the introduction of LDI is often only speculated upon.
There is, to our knowledge, only one retrospective cohort study , and one prospective non-randomized study  that investigated the therapeutic impact of the introduction of laser Doppler imaging. Petrie et al. reported a lower rate of operative interventions (6.8% before and 2.2% after, p= 0.029) in a pediatric burn population after the introduction of LDI and a reduced length of hospital stay of the surgical treated patients (15.1 days before and 9.8 days after, no p-value). The overall length of stay was 3.4 days in 235 patients before and 2.1 days in 270 patients after the introduction of the LDI . Because of the retrospective nature of this study, other factors than the introduction of LDI alone could be responsible for the therapeutic changes . In the study of Kim et al.  the impact of LDI on surgically treated pediatric patients with burns was investigated. The mean time to decision making for grafting procedures was shorter in the LDI group compared to the clinically assessed group (8.9 vs. 11.6 days, p= 0.01). Because of the non-randomised design, it is unclear whether this can be contributed to the LDI or to other differences between the groups.
Thus, current research gives some indications on the diagnostic and therapeutic impact of the LDI in burm care. However, randomised studies in both pediatric and adult patients with burns are lacking.
The introduction of LDI possibly leads to a cost reduction in burn care, by preventing unnecessary surgery [3, 4], and reducing length of hospital stay . However, no prospective studies are available on the costs and the possible cost reduction of LDI in burn care, nor are cost-effectiveness studies. Therefore, we can conclude that is it still unclear whether LDI actually influences diagnostic and therapeutic decisions, patient outcomes and costs, and thus adds to the quality of care.
The aim of our study is to analyse the effectiveness and cost-effectiveness of LDI in burn care. The effect of the use of LDI in burn care on decision making, on clinical outcomes, on costs, and on cost effectiveness will be assessed. The current diagnostic strategy in burn depth assessment (clinical assessment) is compared with the new diagnostic strategy: LDI in combination with clinical assessment. We expect that LDI in combination with clinical assessment can lead to earlier excision and grafting in Dutch burn care. With the results of this cost-effectiveness study, we aim to provide a guidance to decide whether this instrument should be implemented in Dutch burn care.