Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

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.

Keywords: adherence; compliance; guidelines; living systematic review; protocol; traumatic brain injury.

FIG. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of the selection process. Reasons for exclusion full text: Study design: the study was no prospective or retrospective cohort study, randomized controlled trial, clinical trial, cross-sectional study, or time series; Guideline: the study did not describe a guideline, the guideline was local or not evidence-based, the guideline was not implemented or disseminated before the study period; Adherence: the study did not measure adherence per patient, adherence was self-reported; traumatic brain injury (TBI): the study was not about patients with TBI; Setting: the study was not conducted during the hospital and pre-hospital setting; Language: the study was not published in English; Solely about children: the study did not include adults. Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6: e1000097.

FIG. 2.

Percentage guideline adherence for various guideline recommendations. Figure displays lowest, highest, and mean percentages adherence for various guideline recommendations. Numbers correspond with number of guideline recommendation and not to individual studies, because some studies reported on multiple guideline recommendations. “Other” is a summary measure of the following: Brain Trauma Foundation (BTF) intensive care unit protocol for patients with severe traumatic brain injury, BTF hyperventilation, BTF barbiturates, BTF antiseizure prophylaxis, BTF intracranial pressure (ICP) directed therapy, and BTF craniotomy. NICE, National Institute for Health and Care Excellence; CT, computed tomography