Abstract
Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias.
Highlights
Traumatic brain injury (TBI) is the main cause of mortality from injury in people under 45 years of age[1] and leads to US$60 and €33 billion in medical costs in the USA2 and Europe[3] each year
We used the Cochrane definition to identify systematic reviews; we considered a review to be systematic if it clearly stated a set of objectives and reported explicit eligibility criteria, an extensive search strategy[28, 29] and reproducible methods to identify, select, and critically appraise the findings of the included systematic reviews.[22]
Systematic reviews on therapeutic interventions mainly focussed on the Glasgow Outcome Scale (GOS) or GOS-Extended, mortality, or adverse events in patients with moderate to severe TBI
Summary
Traumatic brain injury (TBI) is the main cause of mortality from injury in people under 45 years of age[1] and leads to US$60 and €33 billion in medical costs in the USA2 and Europe[3] each year. Low-value clinical practices, defined as ‘a test or procedure that is not supported by evidence and/or could expose patients to unnecessary harm’[8,9,10,11,12,13,14,15] consume up to 30% of healthcare resources.[9, 16] In the past decade, the medical community has turned towards the de-adoption of low-value practices as a promising means to reduce the strain on healthcare budgets, free-up resources and reduce harm to patients.[17] Physicians report using low-value practices because of a lack of alternative treatment options, fear of legal consequences, and a lack of guidelines on lowvalue care.[15, 18] The Brain Trauma Foundation, among others, publishes guidelines on TBI care.[19] emphasis is on practices that should be adhered to rather than practices that should be avoided. The objective of the present study was to synthesize the evidence on potentially low-value intra-hospital clinical practices in acute TBI in adults
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