Rajajee Venkatakrishna
Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
Neurocrit Care. 2025 May 29. doi: 10.1007/s12028-025-02292-3.
Guideline-concordant care of patients with brain injury may improve outcomes. Guidelines developed in high-income countries (HICs) may overlook important considerations in low- and middle-income countries (LMICs), where resources are often constrained. Many LMICs lack resources for guideline development. Professional societies in HICs can achieve greater worldwide impact through a focus on LMIC concerns during guideline development. Guideline panels that address LMIC concerns should include experts from LMICs and frame population, intervention, comparison, and outcome (PICO) questions appropriate to these settings. The greatest challenge to LMIC-focused guidelines is the paucity of high-quality evidence. Recommendations may be weak or conditional because of reliance on indirect data and observational studies. Methods to evaluate cost-effectiveness developed by the World Health Organization may be useful in addressing the value of system-based interventions such as trauma centers. However, marked variability exists within LMICs in the ability of individuals and centers to access and afford treatments. It is challenging, therefore, for guidelines panels to recommend that expensive but potentially beneficial individual treatment options considered appropriate in HICs not be used in LMICs based on cost considerations alone. Rationing of intensive care unit beds and other resources is unfortunately common in resource-constrained regions. LMIC-focused guidelines on accurate prognostication may allow for better-informed counseling of surrogates and goals of care discussions. This may prevent potentially devastating out-of-pocket expenditure when the probability of meaningful recovery is low. A useful approach to LMIC-focused neurocritical care PICOs may be to posit a situation in which the expensive but potentially beneficial intervention is unavailable, and the question is framed around feasible alternatives in the local environment. This will allow for the possibility that the preferred expensive intervention may be available in some LMIC settings but unavailable in others. Examples include alternative management strategies when tools such as invasive intracranial pressure monitoring or continuous electroencephalography are unavailable. Guidelines that consider LMIC-specific concerns are feasible and may improve the care of critically ill patients with neurological illness worldwide.
遵循指南对脑损伤患者进行护理可能会改善预后。高收入国家（HICs）制定的指南可能会忽略低收入和中等收入国家（LMICs）的重要考量因素，因为这些国家的资源往往有限。许多低收入和中等收入国家缺乏制定指南的资源。高收入国家的专业学会可以通过在指南制定过程中关注低收入和中等收入国家的问题，在全球范围内产生更大的影响。解决低收入和中等收入国家问题的指南小组应包括来自低收入和中等收入国家的专家，并提出适合这些环境的人群、干预措施、对照和结局（PICO）问题。以低收入和中等收入国家为重点的指南面临的最大挑战是高质量证据的匮乏。由于依赖间接数据和观察性研究，建议可能较弱或有条件。世界卫生组织制定的评估成本效益的方法可能有助于评估创伤中心等基于系统的干预措施的价值。然而，在低收入和中等收入国家，个人和中心获得和负担治疗的能力存在显著差异。因此，指南小组仅基于成本考虑就建议在高收入国家被认为合适的昂贵但可能有益的个体治疗方案在低收入和中等收入国家不使用，这具有挑战性。不幸的是，在资源有限的地区，重症监护病房床位和其他资源的配给很常见。以低收入和中等收入国家为重点的关于准确预后的指南可能有助于为替代决策者提供更明智的咨询，并进行关于护理目标的讨论。当有意义的康复可能性较低时，这可能会防止潜在的毁灭性自付费用。一种适用于以低收入和中等收入国家为重点的神经重症监护PICO的有用方法可能是设想一种情况，即昂贵但可能有益的干预措施无法获得，问题围绕当地环境中的可行替代方案展开。这将考虑到在一些低收入和中等收入国家环境中可能可以获得首选的昂贵干预措施，但在其他国家则无法获得的可能性。例如，当诸如有创颅内压监测或连续脑电图等工具无法获得时的替代管理策略。考虑到低收入和中等收入国家特定问题的指南是可行的，可能会改善全球范围内患有神经系统疾病的重症患者的护理。
