Introduction Traumatic brain injury (TBI) leads to 50 000 deaths, 85 000 disabilities and costs $60 billion each year in the USA. Despite numerous interventions and treatment options, the outcomes of TBI have improved little over the last three decades. In a previous scoping review and expert consultation survey, we identified 13 potentially low-value clinical practices in acute TBI. The objective of this umbrella review is to synthesise the evidence on potentially low-value clinical practices in the care of acute TBI.
Methods and analysis Using umbrella review methodology, we will search Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, International Prospective Register of Systematic Reviews (PROSPERO) and PubMed to identify systematic reviews evaluating the effect of potential intrahospital low-value practices using tailored population, intervention, comparator, outcome and study design questions based on the results of a previous scoping review. We will present data on the methodological quality of these reviews (Assessing the Methodological Quality of Systematic Reviews-2), reported effect sizes and strength of evidence (Grading of Recommendations, Assessment, Development and Evaluation).
Ethics and dissemination Ethics approval is not required as original data will not be collected. Knowledge users from five healthcare quality organisations and clinical associations are involved in the design and conduct of the study. Results will be disseminated in a peer-reviewed journal, at international scientific meetings and to clinical, healthcare quality and patient–partner associations. This work will support the development of metrics to measure the use of low-value practices, inform policy makers on potential targets for deimplementation and in the long term reduce the use of low-value clinical practices in acute TBI care.
PROSPERO registration number CRD42019132428.
- low-value clinical practices
- traumatic brain injury
- umbrella review
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Strengths and limitations of this study
State-of-the-art synthesis of evidence on low-value clinical practices in the care of acute traumatic brain injury (TBI).
Represents a crucial step towards the deimplementation of low-value practices in acute TBI care.
Adopts an integrated knowledge translation model to ensure the results are relevant to decision makers.
For feasibility reasons, our synthesis is restricted to systematic reviews published in English since 1990.
The scope of review and the inclusion of systematic reviews precludes meta-analysis.
Traumatic brain injury (TBI) is the main cause of mortality from injury in people under 45 years of age,1 and it leads to approximately US$60 and €33 billion in total medical costs in the USA2 and Europe3 each year, respectively. Moreover, outcomes following TBI have not improved significantly in the last four decades.4 5 Intervention and treatment options for TBI are multiple, but many lack robust evidence of their effectiveness.6 7
Low-value clinical practices, defined as a test or procedure that is not supported by evidence and/or could expose patients to unnecessary harm8–15 consume up to 30% of healthcare budgets.9 16 In the past decade, the medical community has turned towards the deimplementation of low-value practices as a promising means to reduce the strain on healthcare budgets, free-up resources and reduce harm to patients.17 Physicians report using low-value practices because of a lack of alternative treatment options, fear of legal consequences but also because of lack of guidelines on low-value care.15 18 The Brain Trauma Foundation, among others, publish guidelines on TBI care.19 However, emphasis is on practices that should be adhered to rather than practices that should be avoided. Choosing Wisely publish recommendations specifically targeting low-value practices but few pertain to TBI care and many are based uniquely on expert consensus.11 A previous scoping review and expert consultation survey identified 13 potentially low-value clinical practices in acute TBI care.20 These practices represent potential targets for guidelines, overuse metrics and deimplementation interventions. However, before recommendations can be made, we need to synthesise the evidence base for these practices.
Interventions and treatment options for acute TBI have been the subject of multiple systematic reviews.21 22 Given this large body of available evidence, evidence maps have previously been used to summarise evidence from systematic reviews on acute TBI interventions.7 23 However, these evidence maps were not designed to target low-value practices and focused on moderate to severe TBI when the mild TBI population represent great potential for reducing low-value care. In addition, previous reviews have not provided a synthesis of effect sizes or strength of evidence. The objective of the present study is to synthesise the evidence on potentially low-value intrahospital clinical practices in acute adult TBI.
Methods and analysis
Given the multitude of systematic reviews available for the clinical practices identified as potentially low-value (over 60 were identified in our scoping review), we opted to conduct an umbrella review (a systematic review of systematic reviews).20 While the former aimed to fill a knowledge gap on medical overuse for acute injury care by identifying all potential low-value clinical practices, the latter will synthesise the evidence on the low-value practices pertaining to TBI. The review will be conducted according to published guidelines.24–26 In the absence of reporting guidelines for umbrella reviews, we will use the applicable Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Protocols.27
The project steering committee comprising clinicians (two emergency physicians, seven critical care physicians, one neurosurgeon), methodologists (four) and health system managers (three) used the population, intervention, comparator, outcome and study design (PICOS) framework to develop specific research questions for each potentially low-value clinical practice (table 1).20 28 We will consider systematic reviews of original studies evaluating the effectiveness of predetermined clinical practices in acute TBI in adults (≥16 years old) without restriction on location of publication but limited to studies published in English since 1990.25 26
We will use the Cochrane definition to identify systematic reviews. We will consider a review to be systematic if it clearly stated a set of objectives and reported explicit eligibility criteria, an extensive search strategy (a refined search strategy ran on Medline or Cochrane Library and at least one other database)29 30 and reproducible methods to identify, select and critically appraise the findings of the included studies.24
Primary and secondary outcomes were identified for each of the evaluated clinical practices by the project steering committee and are described in a PICO format in table 1.
In consultation with an information specialist, we will develop comprehensive literature search strategies separately for each clinical practice to be studied (see table 2 for a preliminary search strategy in PubMed). We will search systematic reviews using the Cochrane Library, Excerpta Medica Database (Embase), Epistemonikos,31 PubMed and the International Prospective Register of Systematic Reviews32 from 1990 to up to 6 months prior to submission for publication. Using a snowball approach, we will screen the references of included studies in addition to previous reviews on this subject.7 21–23 33
We will manage all citations with EndNote software V.X8.2 (Clarivate Analytics, 2014). We will identify and remove duplicates using electronic and manual screening.34 To ensure reliability when selecting studies for a given practice, two sets of 100 citations will independently be evaluated and then discussed by the reviewers. Pairs of reviewers (PAT, LM, IF, KMB) will then independently screen all identified records using titles, abstracts and full texts, consecutively. Any disagreement will be resolved through discussion between reviewers and, if necessary, consultation with a senior author (AFT). Potentially eligible studies excluded using full texts will be described in a PRISMA flow chart.
Data items and abstraction process
Using a standardised data abstraction form piloted on a representative sample of five studies, pairs of experienced reviewers (PAT, LM, IF, KMB) will independently extract the following data: first author, title, year of publication, databases used and date of the last search; population(s), intervention(s), comparator(s), outcome(s) and study designs included; measures of association and their respective measure of heterogeneity; tools used to assess the quality (risk of bias) of original studies and overall rating from the authors. Any disagreement will be resolved through discussion between reviewers and, if necessary, consultation with a senior author (AFT). When information is available in figures only, we will abstract graphical data using computer-assisted software.35 36 Furthermore, we will contact study authors (up to three email attempts) when information is unclear or unavailable.
Methodological quality assessment
Two reviewers (PAT, LM) will independently critically appraise the quality of systematic reviews using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR-2) tool.37 Methodological quality will be categorised as low (0–3), medium (4–7) and high (8–11).
Results will be presented according to current recommendations for umbrella reviews.38 For each low-value practice, we will present the number of studies, study designs and patients included, the quality of the reviews (AMSTAR-2), effect sizes for primary and secondary outcomes (forest plots) and strength of recommendations (Grading of Recommendations, Assessment, Development and Evaluation).
To ensure the feasibility of the review, we will restrict our search to low-value practices identified in the scoping review and expert consultation study, which may lead us to miss some low-value practices. However, given the robust search strategy used in our scoping review and the fact that experts were asked to add any other practices they considered low value, it is unlikely that important low-value practices have been missed. By targeting systematic reviews rather than original studies, we may miss some evidence. However, given the availability of high-quality, up-to-date reviews in TBI care suggested by our scoping review, we think it unlikely that we will miss a large body of evidence. For certain clinical practices, we may not identify any high-quality, up-to-date reviews. These practices will be the subject of systematic reviews in subsequent phases of the research programme. Finally, for feasibility reasons, we limited this umbrella review to reviews published in English since 1990 as per recommendations for umbrella reviews.25 26 These limitations should have negligible impact on results since few systematic reviews were published prior to 1990 and most published reviews are likely to be written in English.25 26
This review is part of the Canadian Program on Monitoring Low-Value Clinical Practices in Injury Care (Canadian Institutes of Health Research #113664), aiming to evaluate the effectiveness of an audit-feedback module targeting low-value clinical practices in acute injury care. The results of this review will be used to inform the development of quality indicators to be integrated in the audit-feedback module.
We will use state-of-the-art methods to optimise the sensitivity of our search strategy and the robustness of results. Results will be synthesised graphically. Ultimately, this research will inform the development of metrics, guidelines and deimplementation interventions, all targeting low-value injury care. The reduction of low-value clinical practices in acute TBI care has the potential to reduce pressure on strained healthcare budgets, free up resources, reduce adverse events and improve patient outcomes.
Ethics and dissemination
Ethics approval is not required as original data will not be collected. This study will be disseminated in a peer-reviewed journal, international scientific meetings, to knowledge users through clinical and healthcare quality associations (Choosing Wisely Canada, Trauma Association of Canada, American College of Surgeons—Committee on Trauma, International Federation of Emergency Medicine, Institut national d’excellence en santé et en services sociaux, Brain Trauma Foundation) and to patient partners associations (Brain Injury Canada).
Patient and public involvement
No patient or public representatives will be involved in this study.
Contributors P-AT contributed to the elaboration of keywords, developed and tested the search strategy, drafted the manuscript and approved the final version of the manuscript. LM led the development of the protocol and drafted the manuscript with the first author. She acts as guarantor for the review. FLau contributed to developing keywords, validated the search strategy and the data extraction form, revised the manuscript and approved the final version. IF contributed to the elaboration of keywords, the search strategy and the data extraction form, critically revised and approved the final version of the manuscript. PA contributed to working definitions, developed keywords, revised the manuscript and approved the final version. FLam contributed to working definitions, developed keywords, revised the manuscript and approved the final version. MC validated the search strategy and the data extraction form, revised the manuscript and approved the final version. HTS contributed to the development of research objectives, inclusion criteria, the search strategy and the extraction form, developed keywords, revised the manuscript and approved the final version. BJG elaborated inclusion and exclusion criteria and keywords, revised the manuscript and approved the final version. FLec elaborated inclusion and exclusion criteria and keywords, revised the manuscript and approved the final version. JK contributed to the development of research objectives, study definitions, inclusion criteria and the extraction form, developed keywords, revised the manuscript and approved the final version. PL-B contributed to the development of research objectives and inclusion criteria, elaborated keywords, validated the data extraction form, critically revised the manuscript and approved the final version. CT elaborated inclusion and exclusion criteria and keywords, contribution to the development of the conceptual framework and concept definitions, revised the manuscript and approved the final version. AFT elaborated inclusion criteria and clinically significant outcomes, validated the search strategy, elaborated keywords, revised the manuscript and approved the final version.
Funding This research was supported by the Canadian Institutes of Health Research (Foundation grant, #353374 and Embedded Clinician Researcher (PA)). LM, FLau, FLam and MC are recipients of a research salary award from the Fonds de Recherche du Québec—Santé (FRQS). AFT is the Canada Research Chair in Critical Care Neurology and Trauma. The funders had no role in developing this protocol.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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