Can Neurocritical Care Guidelines Developed in High-Income Countries be Relevant to Low- and Middle-Income Countries?

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.