Quality of the Development of Traumatic Brain Injury Clinical Practice Guidelines: A Systematic Review

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.

Guidelines in lower‐middle income countries

“…If guidelines developed in HICs are to be used in LMICs, then the collaborators should include local experts; this will help overcome the previously documented challenge of limited stakeholder involvement in the development of guidelines (Tavender et al, 2011;Alarcon et al, 2013). Involvement of local stakeholders may improve the rates of implementation by identifying and removing barriers to their use, as there is a close association between stakeholder involvement, applicability and guideline implementation (Patel et al, 2016).…”

“…Guidelines developed in collaboration with local experts should include suggestions on how they can be adapted for use in local situations (Patel et al, 2016). Adaptation of existing guidelines to local environments may be a more costeffective means of providing high-quality guidelines (Fervers et al, 2006).…”

“…However, this alternative requires careful planning to avoid additional costs to end-users (Harrison et al, 2013). If a guideline requires a resource not widely available in LMICs, alternatives will be required, such as the use of latex balloons in place of incentive spirometry devices for preventing and treating acute chest syndrome in patients with sickle cell disease (SCD) (Asare et al, 2016;Patel et al, 2016). The successful development of guidelines requires improved knowledge on the effectiveness of existing local and cultural practices; local experts should be able to set priorities and ask relevant research questions that will make such guidelines more applicable (Tol et al, 2014;Israels et al, 2015).…”

“…While it is generally agreed that guideline implementation has a positive influence, for guidelines to be successfully implemented, they must be applicable to the specific environment, based on factors such as availability and cost of required resources, specialized skills, population needs and values (Patel et al, 2016). Guidelines developed by international organizations and professional societies are not easily consulted on the wards or in clinics because they may be voluminous and as a result become inconvenient and time consuming to use.…”

“…They may not only lack relevance but may also not be applicable to LMICs without significant modifications (Patel et al, 2016). Guidelines produced in HICs are often resource neutral and are likely to be unworkable in LMICs with less developed infrastructure and resource deficits.…”