A critical review to traumatic brain injury clinical practice guidelines

A Critical Appraisal of the Congress of Neurological Surgeons Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma

Background and objective Thoracolumbar spine trauma (TST) is frequently associated with spinal cord injury and other soft tissue and bony injuries. The management of such injuries requires an evidence-based approach. This study used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to assess the methodological quality of clinical guidelines for the management of TST published by the Congress of Neurological Surgeons (CNS). Methods All clinical guidelines on TST published by CNS until 2020 were assessed. Five appraisers from three international centers evaluated the quality of eligible clinical guidelines by using AGREE II. Mean AGREE II scores for each domain were determined. In higher-quality domains, the scores for individual items were analyzed. Results A total of 12 guidelines published by CNS on TST were assessed. Mean scores for all six domains were as follows: Scope and Purpose (75.2%), Stakeholder Involvement (45.4%), Rigor of Development (57.0%), Clarity of Presentation (58.7%), Applicability (16.9%), and Editorial Independence (64.1%). The mean score for the overall quality of all CNS guidelines was 52.9% [95% confidence interval (CI): 52.2-53.5%]. The overall agreement among appraisers was excellent [intra-class correlation coefficients (ICCs) for each guideline ranged from 0.903 to 0.963]. Conclusions CNS guidelines for the management of TST demonstrated acceptable quality across most domains; however, the domains of Applicability and Stakeholder Involvement could be further improved in future guideline updates. The assessors concluded that all guidelines could still be recommended for clinical practice with or without modifications.

Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review

Background

Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs.

Methods

For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696).

Findings

Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI.

Interpretation

Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations.

Funding

Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).

Critical Assessment of the Guidelines-Based Management of Severe Traumatic Brain Injury with the Appraisal of Guidelines for Research and Evaluation II

BACKGROUND

Severe traumatic brain injury constitutes a clinical entity with complex underlying pathophysiology. Management of patients with severe traumatic brain injury is guided by Clinical Practice Guidelines and Consensus Statements (CPG and CS). The published CPG and CS vary in quality, comprehensiveness, and clinical applicability. The value of critically assessing CPG and CS cannot be overemphasized. The aim of our study was to assess the quality of the published CPG and CS, based on the Appraisal of Guidelines for Research and Evaluation II instrument.

METHODS

A systematic search was performed in PubMed, Scopus, Embase, and Web of Science focusing on guidelines and consensi about severe traumatic brain injury . The search terms used were "traumatic brain injury," "TBI," "brain injury," "cerebral trauma," "head trauma," "closed head injury," "head injury," "guidelines," "recommendations," "consensus" in any possible combination. The search period extended from 1964 to 2021 and was limited to literature published in English. The eligible studies were scored by 4 raters, using the Appraisal of Guidelines for Research and Evaluation II instrument. The inter-rater agreement was assessed using the Cronbach's alpha.

RESULTS

Twelve CPG and CS were assessed. Overall, the study by Carney et al. was the most Appraisal of Guidelines for Research and Evaluation II compliant study. In general, the domains of clarity of presentation, and scope and purpose, achieved the highest scores. The lowest inter-rater agreement in our analysis was "fair."

CONCLUSIONS

The purpose of our study for assessing the quality of CPG and CS was served. We present the strong and weak points of CPG and CS. Our findings support the idea of periodically updating guidelines and improving their rigor of development.

Validation of Brain Injury Guidelines in the Elderly Trauma Patient Presenting at a Level Two Trauma Center

Retrospective analysis, validating the brain injury guideline (BIG) in the management of traumatic head injury in our level II trauma center after implementation of the protocol, and compare the outcomes to those seen before the protocol, of 542 patients seen in the Emergency Department (ED), with head injury between 2017 and 2021 was completed. Those patients were divided into two groups: Group 1 (pre BIG protocol implementation) and Group 2 (post BIG protocol implementation). Data included age, race, length of stay (hospital and ICU), comorbid conditions, anticoagulant therapy, surgical intervention, GCS, ISS, findings of head CT and any subsequent progression, mortality, and readmission within one month. Student's t-test and Chi-square test were used for statistical analysis. There were 314 patients in group 1 and 228 patients in group 2. Mean age of group 2 was significantly higher than group 1 (67 vs 59 years, p=0.0001), however their gender was similar. Data available on 526 patients were classified as BIG 1=122, BIG 2=73, and BIG 3=331 patients. Post-implementation group were older (70 vs 44 years, P=0.0001) with more females (67% vs 45%, P=0.05) and had significantly more than 4 comorbid conditions (29% vs 8%, P=0.004), with the majority presented with a size of 4 mm or less of acute subdural or subarachnoid hematoma. No patient in either group had progression of their neurological examination, neurosurgical intervention, or readmission.. Elderly trauma patients may benefit from implementation of BIG criteria protocol, thus reducing cost of patient care, however a larger sample size is needed.

A systematic review protocol for assessing equity in clinical practice guidelines for traumatic brain injury and homelessness

Background

When used optimally, clinical practice guidelines (CPGs) can reduce inappropriate variations in practice, improve application of research to practice, and enhance the quality of healthcare. However, a common criticism, despite its potential, is the lack of consideration for equity and disadvantaged populations.

Objectives

This protocol is for a systematic review of CPGs for traumatic brain injury (TBI) and homelessness that aims to assess (1) the extent to which evidence regarding TBI and homelessness is integrated in CPGs for homelessness and TBI, respectively, and (2) equity considerations in CPGs for TBI and homelessness.

Methods and analysis

The methodology for this review is guided by the PRISMA-P, validated search filters for CPGs, and methodological guides to searching systematic reviews and gray literature. CPGs will be identified from (a) databases for peer-reviewed literature (MEDLINE, Embase, CINAHL, and PsycInfo), (b) targeted websites and Google Search for gray literature, and (c) reference lists of peer-reviewed and gray literature that meet the eligibility criteria. Searching for gray literature, including from guideline-specific resources, is a critical component of this review and is considered an efficient approach to identifying CPGs, given the low precision of searching peer-reviewed databases. Two independent reviewers will screen all articles based on pre-determined eligibility criteria. A narrative synthesis will be conducted to identify the proportion of CPGs that integrate evidence about TBI and homelessness and how TBI and homelessness is or is not integrated in CPGs. Quality appraisal will take the form of an equity assessment of CPGs and will be completed independently by two reviewers.

Conclusion

This protocol outlines the methodology for a systematic review of CPGs for TBI and homelessness. The resulting systematic review from this protocol will form an evidence-based foundation to advance CPGs for individuals with lived experience of TBI and homelessness.

Systematic review registration

identifier: CRD42021287696.

Quality assessment of kidney cancer clinical practice guidelines using AGREE II instrument: A critical review

BACKGROUND

Evidence-based guidelines are expected to provide clinicians with explicit recommendations on how to manage health conditions and bridge the gap between research and clinical practice. However, the existing practice guidelines(CPGs) vary in quality. This study aimed to evaluate the quality of CPGs of kidney cancer.

METHODS

We systematically searched PubMed, Embase, China Biology Medicine disc, and relevant guideline websites from their inception to April, 2018. We identified CGPs that provided recommendations on kidney cancer; 4 independent reviewers assessed the eligible CGPs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The consistency of evaluations was calculated using intraclass correlation coefficients (ICC).

RESULTS

A total of 13 kidney cancer CGPs were included. The mean scores for each AGREEII domain were as follows: scope and purpose-76.9%; clarity and presentation-76.4%; stakeholder involvement-62.8%; rigor of development-58.7%; editorial independence-53.7%; and applicability-49.4%. Two CPGs were rated as "recommended"; 8 as "recommended with modifications"; and 3 as "not recommended." Seven grading systems were used by kidney cancer CGPs to rate the level of evidence and the strength of recommendation.

CONCLUSIONS

Overall, the quality of CPGs of kidney cancer is suboptimal. AGREE II assessment results highlight the need to improve CPG development processes, editorial independence, and applicability in this field. It is necessary to develop a standardized grading system to provide clear information about the level of evidence and the strength of recommendation for future kidney cancer CGPs.