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Meta-Analysis
. 2022 Oct 1;79(10):1049-1058.
doi: 10.1001/jamaneurol.2022.2456.

Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis

Xiuxian Pham  1   2   3 , Jason Ray  2   3   4 , Ary Serpa Neto  1   5   6   7 , Joshua Laing  2   3 , Piero Perucca  2   3   8   9 , Patrick Kwan  2   3   10 , Terence J O'Brien  2   3 , Andrew A Udy  1   11
Affiliations
Meta-Analysis

Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis

Xiuxian Pham et al. JAMA Neurol. .

Abstract

Importance: Neurocritical care (NCC) aims to improve the outcomes of critically ill patients with brain injury, although the benefits of such subspecialized care are yet to be determined.

Objective: To evaluate the association of NCC with patient-centered outcomes in adults with acute brain injury who were admitted to intensive care units (ICUs). The protocol was preregistered on PROSPERO (CRD42020177190).

Data sources: Three electronic databases were searched (Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials) from inception through December 15, 2021, and by citation chaining.

Study selection: Studies were included for interventions of neurocritical care units (NCCUs), neurointensivists, or NCC consulting services compared with general care in populations of neurologically ill adults or adults with acute brain injury in ICUs.

Data extraction and synthesis: Data extraction was performed in keeping with PRISMA guidelines and risk of bias assessed through the ROBINS-I Cochrane tool by 2 independent reviewers. Data were pooled using a random-effects model.

Main outcomes and measures: The primary outcome was all-cause mortality at longest follow-up until 6 months. Secondary outcomes were ICU length of stay (LOS), hospital LOS, and functional outcomes. Data were measured as risk ratio (RR) if dichotomous or standardized mean difference if continuous. Subgroup analyses were performed for disease and models of NCC delivery.

Results: After 5659 nonduplicated published records were screened, 26 nonrandomized observational studies fulfilled eligibility criteria. A meta-analysis of mortality outcomes for 55 792 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.75-0.92; P = .001) in those receiving subspecialized care (n = 27 061) compared with general care (n = 27 694). Subgroup analyses did not identify subgroup differences. Eight studies including 4667 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.70-0.97; P = .03) for an unfavorable functional outcome with subspecialized care compared with general care. There were no differences in LOS outcomes. Heterogeneity was substantial in all analyses.

Conclusions and relevance: Subspecialized NCC is associated with improved survival and functional outcomes for critically ill adults with brain injury. However, confidence in the evidence is limited by substantial heterogeneity. Further investigations are necessary to determine the specific aspects of NCC that contribute to these improved outcomes and its cost-effectiveness.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Ray reported funding from the Pharmaceutical Society of Australia and The Limbic supported by unrestricted educational grants from Viatris and Novartis, respectively. Dr Laing reported personal fees from UCB and Eisai outside the submitted work. Dr Perucca reported speaker honoraria or consultancy fees to his institution from Chiesi, Eisai, LivaNova, Novartis, Sun Pharma, Supernus, UCB, and The Limbic outside the submitted work and being an associated editor for Epilepsia Open. Dr O’Brien reported grants from the National Health and Medical Research Council during the conduct of the study and grants from UCB Pharma, Eisia, BioGen, and ES Therapeutics outside the submitted work. Dr Udy reported nonfinancial support from Integra LifeSciences (trial consumables) outside the submitted work and being chair of the College of Intensive Care Medicine of Australia and New Zealand Neurocritical Care Special Interest Group. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Meta-analysis of Mortality Outcomes as Risk Ratio (RR) in Critically Ill Adults With Brain Injury Receiving Specialized Neurocritical Care (NCC) and General Intensive Care
Figure 2.
Figure 2.. Subgroup Analysis of Mortality Outcomes by Disease Process
AIS indicates acute ischemic stroke; ICH, intracerebral hemorrhage; NCC, neurocritical care; RR, risk ratio; SAH, subarachnoid hemorrhage; TBI, traumatic brain injury.
Figure 3.
Figure 3.. Subgroup Analysis of Mortality Outcomes by Intervention Type
NCC indicates neurocritical care; RR, risk ratio.
Figure 4.
Figure 4.. Meta-analysis of Poor Functional Outcomes in Critically Ill Adults With Brain Injury
NCC indicates neurocritical care; RR, risk ratio.
See this image and copyright information in PMC

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