The LDI Enigma, Part I: So much proof, so little use

•The cost of purchasing and using LDI is a key barrier for burn centers.•The national health insurance should provide a reimbursement per scanned patient.•Inadequate reimbursement for conservative management encourages excess surgery.•The reluctance to accept the scientific evidence of LDI restricts its routine use.•Organizational structures are a major barrier for the proper implementation of LDI. Laser Doppler imaging (LDI) is still not an ubiquitous part of burn care worldwide despite reported accuracy rates of more than 95%, which is significantly higher than clinical assessment alone (50–75%). The aims of Part I of this survey study are: to identify the most important barriers for the use of LDI and to provide useful recommendations for efficient implementation in routine burn care. The actual interpretation and use of LDI measurements is discussed in the Enigma Part II article. 1. Informative interviews with 15 representatives of burn centers without LDI. 2. A survey among 51 burn centers with LDI by means of an extensive questionnaire. 3. In-depth interviews with 21 of the participating centers. 1. All 15 centers without LDI indicated that cost of purchase in combination with maintenance of the LDI device, as well as personnel costs were the reason for not buying, while 12 (80%) also rated the current scientific evidence as insufficient. 2. Twenty-seven burn centers with an LDI (53%) participated and filled in almost the entire questionnaire. In 5 centers, cost delayed the purchase of LDI. The hospital/department paid for the LDI device in 62% of the burn centers and in 88% also for maintenance and salaries. The LDI operators were mainly surgeons (47%) or nurses (42%). In more than half of the burn centers (52%), between 2 and 5 people were trained and certified to use an LDI. In 50% of burn centers, the interpretation of the LDI scan was done by the same person doing the actual measurements. Eighty-nine percent of the burn centers considered the accuracy of the LDI scan as mainly to almost completely accurate. In case of real discrepancy between clinical diagnosis and LDI, in 48% of the burn centers (13/27) the surgeon still relied more on the clinical diagnosis despite reporting this high or almost complete accuracy rate of the LDI. Barriers for the routine implementation of LDI were: 1. cost of purchasing and using an LDI combined with health care systems that inadequately reimburse non-surgical management; 2. lack of awareness of or ongoing skep