{"id":248,"date":"2023-09-19T20:36:23","date_gmt":"2023-09-19T20:36:23","guid":{"rendered":"https:\/\/newsletters.aans.org\/neurotrauma\/?page_id=248"},"modified":"2023-09-19T20:36:23","modified_gmt":"2023-09-19T20:36:23","slug":"chairs-message","status":"publish","type":"page","link":"https:\/\/newsletters.aans.org\/neurotrauma\/fall-2023\/chairs-message\/","title":{"rendered":"Chair’s Message"},"content":{"rendered":"

Chair\u2019s Message
\nP.B. Raksin MD<\/p>\n

\u201cThere\u2019s an App for that\u201d has become a common refrain. It follows that there\u2019s probably a guideline for that<\/em>, too. (We\u2019ll set aside \u2013 for the moment \u2013 the concept of the guideline App.)<\/p>\n

Suffice it to say that as the publication of evidence-based and evidence-adjacent documents has accelerated in recent years, we have become increasingly accustomed to reaching for bullet point recommendations to inform our clinical practice.<\/p>\n

The more youthful among us may not be fully cognizant of the integral role played by the Trauma Section in the birth of the \u201cO.G.\u201d of evidence-based guidelines \u2013 the Brain Trauma Foundation\u2019s (BTF) Guidelines for the Management of Severe Traumatic Brain Injury (TBI)<\/em>. As the story goes, the first edition grew out of a conversation among Jam Ghajar, Randy Chesnut and Don Marion at the 1993 CNS annual meeting. Surveys had shown wide variation in clinical practice among centers caring for patients with severe head injury. The driving premise was a simple one: Standardization of practice would lead to improved care and better outcomes. And adherence to a rigorous process for data abstraction and the grading of evidence would ensure a product that leaned more heavily on science than expert opinion. The BTF partnered with the Trauma Section for this effort, convening an expert panel that included Ghajar, Chesnut and Marion, as well as other section stalwarts including Ross Bullock, Raj Narayan, Guy Clifton, David Newell, Lawrence Pitts and Jack Wilberger.[i]<\/a><\/p>\n

When the inaugural edition of the severe TBI guidelines was released in 1996, it became the first such document produced by a surgical subspecialty group. The author group sought broad, if not worldwide, dissemination. And the impact of their efforts was measurable. One study \u2013 published out of New York, after a 10-year period of management by these tenets \u2013 demonstrated a significant decrease in mortality following implementation of the guidelines.[ii]<\/a><\/p>\n

While the subsequent three iterations of this document have moved increasingly under the umbrella of the BTF, section members remain active participants in the production process. The BTF work product is revered for the rigor of its methodology, though this arguably comes at a price. Where the available evidence is overwhelmingly low-level or lacking (sadly, pervasive among published neurosurgical studies), the process does not allow for the formulation of a discrete recommendation. The result may be a guideline that provides little in the way of guidance<\/em>. In recognition of this gap, the BTF has engaged in a parallel process to draft recommendations that are more consensus than evidence-based but seek to address the needs of the end user at the bedside.<\/p>\n

In the years since the publication of that primordial contribution to evidence-based practice, guidelines have proliferated within organized neurosurgery. We have built infrastructure for both review (JGRC) and production (CNS Guidelines Committee) of guidelines. More recently, we have introduced the category of practice parameters to address topics for which the available evidence may not rise to a level that would support the creation of an evidence-based guideline, but where neurosurgeons crave direction to inform clinical decision-making. It has also become evident that these documents may serve other purposes \u2013 providing legal protections when the quality of care is contested, a basis for the creation of quality measures, and the argument for reimbursement for neurosurgical services. These applications further fuel the arms race to develop and disseminate new evidence-based work product.<\/p>\n

But we may be at a tipping point. A recent article claims that there are simply not enough hours in a day to provide the guideline-recommended care for primary care patients.[iii]<\/a> In fact, the mean time required for a PCP to provide guideline recommended preventative, chronic disease and acute care to a hypothetical patient panel was estimated as nearly 27 hours per day! Neurosurgeons are known for burning the candle at both ends but not necessarily for bending the space-time continuum.<\/p>\n

It is time to critically re-examine the model, with a focus on the so-called \u201cback end.\u201d Rather than flooding the market with evidence-light guidelines, we should be striving for greater refinement of methodology to collate and distill the available evidence into an appropriately matched instrument to disseminate. And we should direct proportionately greater resources toward defining the needs of the end user. Who is using the documents? How are they being used? Are they applicable? Are they reliable? Do they codify practice? Do they improve outcomes?<\/p>\n

This renewed focus on the \u201cback end\u201d (perhaps counterintuitively) would create a positive feedback loop, informing decisions on the front end of guideline development \u2013 from identification of relevant stakeholders to the creation of the PICO questions to be answered. These are the core elements that influence all that follows in the guideline development process. A guideline that is usable and applicable should be deeply rooted in available evidence, yet grounded in clinical experience; recognize affected groups; be transparent in process; provide recommendations that are practical and practicable; inform safe, quality care and secondarily, suggest a research agenda. Piece of cake, huh?<\/p>\n

[1]<\/a>1Hawryluk G and Ghajar J. Evolution and Impact of the Brain Trauma Foundation Guidelines. Neurosurgery. 2021;89:1148-1156. (DOI:10.1093\/neuros\/nyab357)<\/p>\n

<\/a>2 Farahvar A, Gerber LM, Chiu YL, Carney N Hartl R, Ghajar J. Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring. J Neurosurg. 2012;117(4):729-734.<\/p>\n

[3]<\/a> Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. J Gen Int Med 38(1):47-55 (DOI:10.1007\/s11606-022-07707-x)<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Chair\u2019s Message P.B. Raksin MD \u201cThere\u2019s an App for that\u201d has become a common refrain. It follows that there\u2019s probably a guideline for that, too. 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