Abstract
Traumatic brain injury (TBI) is a leading cause of death worldwide and is increasing exponentially particularly in low and middle income countries (LMIC). To inform the development of a standard Clinical Practice Guideline (CPG) for the acute management of TBI that can be implemented specifically for limited resource settings, we conducted a systematic review to identify and assess the quality of all currently available CPGs on acute TBI using the AGREE II instrument. In accordance with PRISMA guidelines, from April 2013 to December 2015 we searched MEDLINE, EMBASE, Google Scholar and the Duke University Medical Center Library Guidelines for peer-reviewed published Clinical Practice Guidelines on the acute management of TBI (less than 24 hours), for any level of traumatic brain injury in both high and low income settings. A comprehensive reference and citation analysis was performed. CPGs found were assessed using the AGREE II instrument by five independent reviewers and scores were aggregated and reported in percentage of total possible score. An initial 2742 articles were evaluated with an additional 98 articles from the citation and reference analysis, yielding 273 full texts examined. A total of 24 final CPGs were included, of which 23 were from high income countries (HIC) and 1 from LMIC. Based on the AGREE II instrument, the best score on overall assessment was 100.0 for the CPG from the National Institute for Health and Clinical Excellence (NIHCE, 2007), followed by the New Zealand Guidelines Group (NZ, 2006) and the National Clinical Guideline (SIGN, 2009) both with a score of 96.7. The CPG from a LMIC had lower scores than CPGs from higher income settings. Our study identified and evaluated 24 CPGs with the highest scores in clarity and presentation, scope and purpose, and rigor of development. Most of these CPGs were developed in HICs, with limited applicability or utility for resource limited settings. Stakeholder involvement, Applicability, and Editorial independence remain weak and insufficiently described specifically with piloting, addressing potential costs and implementation barriers, and auditing for quality improvement.
Highlights
Traumatic brain injury (TBI) is one of the leading causes of death and disability in both developing and developed countries, with the highest incidences among young people less than 30 years of age [1, 2]
Regarding the severity of TBI, one third of the Clinical Practice Guideline (CPG) were developed for minor or mild TBI [23, 24, 25, 29, 31, 32, 34, 33], another third covered severe TBI [26, 27, 28, 33, 35, 36, 37, 44, 45] and the rest were developed for all levels of TBI severity [30, 37, 38, 39, 40, 41, 42]
Of the 24 assessed CPGs, roughly half (11) were developed by professional organizations [23, 24, 25, 30, 31, 32, 35, 36, 37, 43, 44], four were developed by non-profit organizations [26, 27, 39, 42], three by international committees [41, 33, 34], another three by national institutes or government organizations [37, 38, 40], one from an academic organization [29], one did not specified the type of organization [45], and the remainder of the CPGs were developed by mixture of different organizations: a non-profit professional organization [28] and a professional organization with an academic organization [46]
Summary
Traumatic brain injury (TBI) is one of the leading causes of death and disability in both developing and developed countries, with the highest incidences among young people less than 30 years of age [1, 2]. While the current global burden is unknown, previous conservative estimates indicate an annual incidence of over 10 million people sustaining a TBI leading to hospitalization or death, with road traffic injuries causing a preponderance of cases [1, 3]. The World Health Organization suggests that upwards of 90% of road traffic injury deaths occur in LMIC. These trends have been attributed to the rapid economic growth, urbanization, and motorization but limited infrastructure improvements in LMIC [1, 4]. As the burden of TBI continues to increase globally, appropriate prevention efforts have been limited, especially in LMIC, and healthcare quality remains poor, resulting in disproportionately higher mortality rates [5].
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