[ARTICLE] Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review – Full Text

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 low^5–7 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:

• 1. To quantify adherence to guidelines in adult patients with TBI.

• 2. To explore factors influencing adherence to TBI guidelines in those studies reporting on adherence.

• 3. To examine the association between adherence to guidelines and outcome in patients with TBI in those studies reporting on adherence.

Continue —> Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review | Journal of Neurotrauma

[ARTICLE] Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review – Full Text

ABSTRACT

This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.

Introduction

Traumatic brain injury (TBI) is among the most severe types of injury in terms of both case fatality¹ and long-term implications for survivors.² Treatment of TBI can be complex and expensive.³ Upon clinical examination, TBI is most commonly sub-divided into mild, moderate, and severe, according to the Glasgow Coma Scale (GCS).^4,5 Such categories have been found to be predictive of a patient’s long-term outcome,⁶ although other measures and models also have been tested.^7,8

A previous review of the epidemiology of TBI in Europe concluded that the leading causes of TBI were road traffic collisions, and falls.³ Consequently, in a densely populated and economically advanced area such as the European Union (EU), the potential for prevention of morbidity and mortality is great. The variability in incidence and mechanism of TBI, which may be observed on this mainly contiguous land-mass with a well-developed road network, is also of scientific interest, as it may lead to better prevention of TBI. Countries within the EU adhere to certain multi-national laws and agreements, but nonetheless retain their own law-making and enforcement responsibilities.⁹ This may add further complexity to the understanding of TBI epidemiology, for example, in the contributions of varying road speed limits or the legal restrictions on the availability of firearms. More generally, the issues relating to the contemporary demographic and lifestyle characteristics of the similar countries or regions suggest that epidemiological trends from EU countries also may be applicable to other high income countries.

Considerable variability has been observed between national rates, largely attributable to significant variability in data collection, case ascertainment, and case definition. This has led to calls for standardized definitions and data collection in population-based studies, and an associated paradigm shift in studying TBI and its impact.^10–12

In order to improve the understanding of causes of TBI and the scale of the problem, it is important to analyze the current situation and time trends, using good quality comparable observational studies. One comprehensive systematic review of the epidemiology of TBI in Europe was published nearly ten years ago.³ A recent systematic review,¹³ published as a follow-up to Tagliaferri (2006),³ addresses similar issues but was more restrictive in dates of publication (1990–2014) and has not been set up as a “living” systematic review (i.e., it is not expected that it will be kept up-to-date as new research is published).¹³

The overall objective of this systematic review was to provide a comprehensive, up-to-date summary of TBI epidemiology in Europe by reviewing all relevant observational studies. Specific aims were to determine the incidence, mortality, age, and sex distribution of TBI in Europe, along with the severity and mechanism of injury and time trends. […]

 

Continue —> Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review