Abstract
Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18–100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.
Introduction
Traumatic brain injury (TBI) is a major public health concern affecting approximately 150–300 per 100,000 persons annually in Europe.1 The World Health Organization has predicted that TBI will be one of the leading causes of death and disability worldwide by the year 2020.2
The care for patients with TBI is often complex and multidisciplinary. Guidelines, protocols, and care pathways have been developed to improve quality of care, to reduce variation in practice, and to ensure that evidence-based care is optimally implemented.3
A 2013 systematic review4 found that the use of protocols in the management of severe TBI in the intensive care unit (ICU) led to improved patient outcomes. The findings, however, were based on observational studies that did not report on adherence rates. Without an understanding of adherence rates, the improved outcomes stated in the review cannot be directly attributed to the use of protocols.
Guideline adherence can be defined as the proportion of patients treated according to a guideline recommendation, which often represents evidence-based or best practice care. Previous studies have found that guideline adherence in medicine is generally low5–7 and varies widely across centers,7,8 medical condition,9 types of guideline,10,11 and time period.8,10 As a result, many patients do not receive evidence-based care, while others receive unnecessary care that may even be harmful.5To date, no systematic review of the literature about guideline adherence in TBI has been conducted.
The aim of this systematic review was to provide a comprehensive overview of professionals’ adherence to guidelines in adult patients with TBI. The objectives were threefold:
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1. To quantify adherence to guidelines in adult patients with TBI.
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2. To explore factors influencing adherence to TBI guidelines in those studies reporting on adherence.
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3. To examine the association between adherence to guidelines and outcome in patients with TBI in those studies reporting on adherence.
TBI Rehabilitation 