The efficacy of early elastic bandage in the treatment of subdural effusion after decompressive craniectomy: a meta-analysis

Abstract

Background

We aimed to investigate the safety and efficacy of early elastic bandage in treating subdural effusion after decompressive craniectomy.

Methods

We searched Cochrane Library, Web of Science, Embase, PubMed, CNKI, VIP, and Wanfang databases for randomized controlled trials assessing the effects of early use of elastic bandages on subdural effusion. Studies published from the establishment of the database to March 2024 were retrieved. A risk of bias assessment tool, Cochrane was independently used by two researchers to assess the quality of the included studies. The analysis was conducted using RevMan 5.4 software. Heterogeneity was determined using I² test and P-value. Publication bias was evaluated based on the funnel plot.

Results

Ten studies with 954 patients were included. The results of the meta-analysis showed that the risk of subdural effusion elastic bandage group was lower than the conventional treatment group (HR = 0.46, 95% CI: 0.23–0.92, P = 0.03). In addition, risk of adverse events in the experimental group was lower than that in the control group (HR = 0.46, 95% CI: 0.23–0.92, P = 0.03), and there was no significant difference in GOS ≥ 3 between the experimental group and the control group after treatment (HR = 1.12, 95% CI: 0.89–1.42, P = 0.34). Moreover, the number of patients with hospitalization length ≤ 30 days in the experimental group was better than that in the control group (HR = 1.90, 95% CI: 1.31–2.77, P = 0.0007).

Conclusions

This analysis suggests early elastic bandaging is a promising, low-cost intervention for preventing subdural effusion and reducing hospitalization after decompressive craniectomy, though not for improving neurological function. It’s definitive role in clinical practice should be established by future multinational trials that address the current limitations in evidence quality.

Trial registration

CRD42024551332 (06/06/2024).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-025-04505-w.

Background

Decompressive craniectomy (DC) is a widely used method for treating intractable intracranial hypertension [1]. It has been reported that among patients undergoing DC, the incidence of surgical complications can be as high as 50% [2]. In particular, the incidence of subdural effusion can range from 12.5% to 27.4% [3]. Without treatment, subdural effusion can lead to midline shift, further deteriorating the nervous system damage, and significantly undermining patients’ recovery and quality of life [4]. Additionally, untreated subdural effusion may prolong patients’ hospital stay and increase the economic burden [5]. Therefore, it is crucial to prevent and treat subdural effusion. Several methods have been systematically reviewed to reduce the risk of subdural effusion, but they are not necessarily appropriate for all patients undergoing decompressive craniectomy. Early combined elastic bandages have attracted attention, possessing the advantages of simplicity, convenience, and cost-effectiveness [6, 7], However, the sample size of a single study is small, and the study area, intervention types, and intervention effect are also different. Moreover, whether pressure dressing can decrease the frequency and duration of effusion compared to traditional dressing remains unknown. This study systematically evaluated, analyzed, and compared the intervention effects of elastic bandages on subdural effusion after DC surgery at home and abroad, aiming to explore the safety and efficacy of early combined elastic bandages in treating subdural effusion after decompressive craniectomy.

Material methods

Literature retrieval strategy

We searched the Cochrane Library, Web of Science, Embase, PubMed, CNKI, VIP, and Wanfang databases from the inception to March 2024. We used the combination of subject words and free words to trace the references included in the subject and literature-related review to ensure comprehensiveness. Taking CNKI as an example, the search mode was as follows: SU= (compression bandage + pressure + elastic bandage + bandage + pressure dressing + elastic dressing) AND (Subdural effusion + subdural effusion + subdural effusion + chronic subdural effusion after surgery + subdural external leakage of cerebrospinal fluid + hydrocystoma + subdural + subdural leakage of cerebrospinal fluid + Subdural cystoma). Using PubMed as an example for English search, and the search formula was as follows: #1“compression Bandages”[Mesh]; #2 (Bandage, Compression[Title/Abstract] OR Bandages, Compression[Title/Abstract] OR Elastic Compression Wraps[Title/Abstract] OR Compression Wrap, Elastic[Title/Abstract] OR Compression Wraps, Elastic[Title/Abstract] OR Elastic Compression Wrap[Title/Abstract] OR Wrap, Elastic Compression[Title/Abstract] OR Wraps, Elastic Compression[Title/Abstract] OR Elastic Bandages[Title/Abstract] OR Bandage, Elastic[Title/Abstract] OR Bandages, Elastic[Title/Abstract] OR Elastic Bandage[Title/Abstract] OR Compression Bandage[Title/Abstract] OR Compression Wraps[Title/Abstract] OR Compression Wrap[Title/Abstract] OR Wrap, Compression[Title/Abstract] OR Wraps, Compression[Title/Abstract] OR pressure bandage[Title/Abstract]);

#3 #1OR#2; #4 “Subdural Effusion“[Mesh]; #5(Effusion, Subdural[Title/Abstract] OR Subdural Cerebrospinal Fluid Leakage[Title/Abstract] OR Cerebrospinal Fluid Leakage, Subdural[Title/Abstract] OR Cerebrospinal Fluid Effusion, Subdural[Title/Abstract] OR Subdural Cerebrospinal Fluid Effusion[Title/Abstract] OR Hygroma, Subdural[Title/Abstract] OR Subdural Hygroma[Title/Abstract]);#6 #4 OR #5; #7 #3 AND #6.

Experiment

Randomized controlled trials treating subdural effusion with elastic bandages (Randomized controlled trials, RCT).

Inclusion criteria

Object of study

Randomized controlled trials were included in this study. The study subjects were patients with severe traumatic brain injury (TBI) or hypertensive intracerebral hemorrhage who underwent decompressive craniectomy. The interventions were compression dressing with elastic bandages alone or combined with routine nursing in the experimental group and routine nursing in the control group.

Outcome indicators

The following outcomes were assessed in this study: the incidence of subdural effusion, adverse events, postoperative Glasgow outcome scale (GOS) score ≥ 3, and the length of hospital stay ≤ 30 days.

Exclusion criteria

Exclusion criteria were as follows: (1) full-text version not available; (2) data could not be obtained; (3) updated conference papers by the same team; (4) low-quality studies that did not report inclusion and exclusion criteria and did not specify the criteria used for assessing outcomes.

Literature screening and data extraction

Two researchers independently reviewed data and collected the results in a structured dataset. They comprehensively assessed the data for duplication. Discrepancies regarding the inclusion of each trial were discussed by a third independent investigator and consensus was reached after in-depth discussion to ensure the accuracy of the results. Data were finally extracted. The included references were the first author, year of publication, country, sample size, intervention measures, postoperative GOS of patients, incidence of subdural effusion, and adverse reactions. Data were rechecked by another analyst after data extraction.

Literature quality evaluation

In this study, we used Cochrane Manual criteria to comprehensively evaluate the risk of bias of the included randomized controlled studies [8]. If the study fully conformed to the requirements of this manual, the risk of bias was minimized and the study quality was classified as A. We assessed bias in randomization, bias in deviation from established interventions, bias in missing outcome data, bias in outcome measurement, bias in selective reporting of the results, and overall bias. In case of any objections during the evaluation process, we conducted an in-depth discussion or consulted with a third researcher to ensure the accuracy of the evaluation.

Statistical analysis

We used RevMan5.4 software to analyze data. Weighted mean difference (MD) or standard mean difference (SMD) was used as the effect size. Relative risk (RR) was used as the effect size for count data, and bicategorical variable analysis was conducted for qualitative data. I² was used to assess heterogeneity among the included studies. Heterogeneity was considered small when P > 0.1 and I² ≤ 50%, and the fixed-effect model was used for analysis. Heterogeneity was considered huge when P < 0.1 and I² > 50%. Subgroup analysis was conducted to explore the source of heterogeneity, and the test level α = 0.05.

To assess the robustness of our findings and explore the impact of study quality heterogeneity, we performed sensitivity analyses by excluding studies with higher risk of bias. Specifically, we re-analyzed the primary outcomes (subdural effusion) after removing studies that: (1) Did not describe randomization methods in detail (only mentioned “randomized” without specifying methods); (2) Had unclear allocation concealment; (3) Incomplete outcome data reporting. The pooled effect estimateswere recalculated after each exclusion, and results were compared with the primary analysis.

Results

Literature screening process and results

In total, 954 Chinese and English studies were retrieved and 422 studies were excluded after full-text review, consisting of irrelevant, conference abstracts, incomplete data, and review articles, leaving 10 studies for inclusion. The literature selection process is shown in Fig. 1.

Fig. 1.

Flow chart of systematic search and literature screening

Basic characteristics of the included literature

Finally, 10 articles were included. In total, 361 patients were included in the experimental group and 405 patients in the control group. The studies were mostly from China. Seven articles measured the outcome of subdural effusion [6, 7, 9–13]. Three studies evaluated adverse events [10, 14, 15], three studies assessed GOS score ≥ 3[11, 15, 16], and 3 studies measured hospitalization ≤ 30 days [6, 7, 9]. The basic characteristics of the included studies are shown in Table 1.

Table 1.

Basic characteristics of the included studies (n = 10)

Article	Publish	Country	Sample size Example, test group/ control group	Age (years, test group/control group)	Intervention group measures	Control group measures	Outcome
Xiaocong Wei	2015	China	25/25	28ཞ74/29ཞ74	Elastic bandage compression bandage	Conventional dressing	①
Shuojun Hua	2014	China	29/30	46.5 ± 13.1/46.6 ± 14.2	Elastic bandage compression bandage	Conventional dressing	②
Weidong Sun	2015	China	34/34	41.6 ± 8.1/40.9 ± 7.6	Elastic bandage compression bandage	Conventional dressing	②③
Meng Wang	2017	China	37/37	27.15 ± 1.03/27.14 ± 1.04	Elastic bandage compression bandage	Conventional dressing	① ②
Shasha Xu	2022	China	38/40	59.31 ± 12.69/57.67 ± 12.33	Sports bandage	Conventional dressing	③
Xihong Xing	2016	China	26/29	27ཞ75/19ཞ80	Pressure dressing	Conventional dressing	① ③
Yuqiang Yao	2015	China	27/36	44.3 ± 14.9/42.8 ± 19.1	Elastic bandage compression bandage	Conventional dressing	①
Gangzhu Xu	2012	China	63/86	age ≤ 50, 54example, >50, 9example/ age ≤ 50, 72example, >50, 14example	Pressure dressing	Conventional dressing	①④
GangZhu Xu	2014	China	82/87	age ≤ 50, 70example  > 50, 12example/ age50, 72example, > 50, 15example	Elastic bandage compression bandage	Conventional dressing	①④
Wangyong Huang	2021	China	62/61	53 ± 13/53 ± 12	Pressure dressing	Conventional dressing	①④

① Incidence of postoperative subdural effusion; ② Incidence of adverse reactions; ③ GOS score ≥ 3 points; (4) Duration of hospitalization ≤ 30 days

Literature quality assessment

RCT quality evaluation indicated that they have grade B [8]. Two RCTs described the specific method of randomization using the random number table method, and other studies only mentioned randomization. The baseline characteristics of all included studies were comparable, and implementers and researchers were not blinded. The number and reasons for dropping out or missing follow-up were not reported. No intention-to-treat analysis was conducted. None of the studies reported allocation concealment.

Results of meta-analysis

Effect of elastic bandage on the incidence of postoperative subdural effusion

Seven articles reported the effect of elastic bandage on the incidence of postoperative subdural effusion. The heterogeneity test revealed no statistical heterogeneity among the included studies, and the risk of subdural effusion was greater in the control group than in the experimental group (HR = 0.38, 95% CI: 0.27–0.52, I² = 0%, P < 0.00001) [6, 7, 9–13]. A fixed effect model was used for analysis. Compression of elastic bandage reduced the incidence of subdural effusion at the general level, and the difference in the incidence of subdural effusion was statistically significant after treatment (P < 0.001) (Table 2).

Table 2.

Forest plots of the incidence of subdural effusion in the treatment and control groups

Effect of elastic bandage on the incidence of adverse events in patients with subdural effusion

Three articles reported the effect of elastic bandage on the incidence of adverse events among patients with subdural effusion [10, 14, 15]. Research indicates that early application of elastic bandage compression bandaging can effectively prevent and reduce the occurrence of complications such as hydrocephalus and intracranial infection after DC.The heterogeneity test indicated no heterogeneity among the included studies, and the risk of adverse events was greater in the control group than in the experimental group (HR = 0, 95% CI: 0.23–0.92, I² = 15%, P = 0.03). A fixed effect model was used for analysis, showing a significant difference in the incidence of adverse reactions between the experimental group and the control group after different treatment methods at the overall level (P < 0.05) (Table 3).

Table 3.

Forest plots of adverse reactions among patients with subdural effusion in the experimental group and the control group

Effect of elastic bandage on subdural effusion patients with GOS ≥ 3

Three studies reported the associations of GOS ≥ 3 between the two groups, and the heterogeneity test showed no heterogeneity among the included studies (HR = 1.12, 95% CI: 0.89–1.42, I² = 0%, P = 0.34) [11, 15, 16]. A fixed effect model was used to analyze data. At the overall level, the beneficial effect of elastic bandage compression on the GOS score was not significant (Table 4).

Table 4.

Forest plots of subdural effusion patients with GOS score ≥3 in the experimental group and the control group

The hospital stay of patients with subdural effusion treated with elastic bandage was less than 30 days

Three studies reported the association between the two treatments and subdural effusion after treatment for ≤ 30 days in the hospital. The heterogeneity test showed no heterogeneity among the included studies, and the number of patients with hospitalization length ≤ 30 days in the experimental group was smaller than that in the control group (HR = 1.90, 95% CI: 1.31–2.77, I² = 0%, P = 0.0007) [6, 7, 9]. A fixed effect model was used for analysis and it was found that elastic bandages significantly reduced the length of hospital stay of patients at the overall level (P < 0.001) (Table 5).

Table 5.

Forest maps of patients with subdural effusion in the experimental group and the control group with hospital stay ≤30 days

Sensitivity analysis for study quality

To assess the impact of study quality, we performed sequential single-study exclusion analyses. The pooled hazard ratio (HR) for reduced subdural effusion incidence remained highly stable (range: 0.36–0.42) after excluding any individual study. All confidence intervals excluded 1 (95% CI lower limit: 0.25–0.30, upper limit: 0.51–0.59) with persistent extreme significance (P < 0.00001). Null heterogeneity (I²=0%) across all analyses confirmed that the primary conclusion was uninfluenced by any single study, robustly supporting an approximately 62% risk reduction (1–0.38) with elastic bandages.

Discussion

Reduction in subdural effusion incidence

This meta-analysis showed that compression with elastic bandage can effectively reduce the risk of subdural effusion after bone flap removal. The sensitivity analysis confirms robust findings—sequential single-study exclusions yielded stable pooled hazard ratios (HR range: 0.36–0.42) for elastic bandages in reducing subdural effusion incidence, with confidence intervals consistently excluding null (95% CI: 0.25–0.59) and persistent null heterogeneity (I²=0%). Craniotomy under decompression is conducted when intracranial pressure is elevated and does not respond to medical therapy. Various complications may occur after DC surgery. Subdural effusion is one of these complications. Currently, the mechanism of subdural effusion after bone flap removal remains unclear. Some scholars have shown that subdural effusion is closely associated with the leakage of cerebrospinal fluid due to arachnoid tear after trauma [17]. During TBI, brain tissue moves rapidly in the cranial cavity due to external force, which may lead to arachnoid tear. Cerebrospinal fluid flows through the hiatus into the subdural space between the dura and arachnoid to accumulate and form subdural effusion [18, 19]. Also some scholars have also shown that glymphatic dysfunction after TBI is the core mechanism of the occurrence of complications such as subdural effusion[20].During TBI, the loss of polarity of Aquaporin-4(AQP4)water channel proteins and the obstruction of the paravascular clearance pathway drive the accumulation of metabolic toxic substances and the neuroinflammatory cascade reaction, ultimately disrupting the function of the glymphatic system and causing subdural effusion Currently, there are limited treatment options for subdural effusion after craniotomy. In terms of medication, acetazolamide or atorvastatin can be used for treating subdural effusion after craniotomy [21]. A meta-analysis by Ling et al. summarized various surgical treatment methods for subdural effusion after decompressive craniectomy [22]. Subarachnoid puncture drainage, thoracic or abdominal shunt, and early skull repair can be used for treating subdural effusion after craniotomy [2, 23]. The specific treatment measures still need to be determined based on the actual condition of the patient. However, no matter which treatment method is chosen, the economic condition of the patient and the patient’s condition should be considered to minimize the burden of the patient. Therefore, we need to actively prevent subdural effusion after decompressive craniectomy. As a new method to prevent and treat subdural effusion, elastic bandage can be considered based on patients’ medical conditions and economic situations. Huang et al. proposed that elastic bandages should be used to wrap the skull defect starting from the 4th to the 7th day after DC (usually after the patient’s intracranial drainage tube is removed), with the restraint pressure of the elastic bandages being of moderate intensity. During the subsequent treatment process, the restraint pressure of the elastic bandages should be appropriately adjusted according to the patient’s condition, which can effectively prevent and treat subdural effusion. Elastic bandages should be viewed as a potentially non-invasive, low-cost prophylactic or early-stage treatment. They are not a substitute for definitive surgical management in cases of large or symptomatic effusions. Future studies should include comparative effectiveness trials that directly compare elastic bandages to watchful waiting, medical management, or their use as an adjunct to other therapies to clearly define their role in the clinical algorithm.

Safety of compression bandage

This meta-analysis found that early use of elastic bandages was safe and effectively prevented complications, such as intracranial infection, acute encephalocele, and recurrent subdural effusion. These complications may lead to brain abscess, meningitis, intracranial hypertension, compressive damage to the brain tissue, neurological dysfunction, and other symptoms. In severe cases, they can lead to brain dysfunction and even death [24]. Although it has shown good efficacy and is easy to apply in subdural effusion, due to the small number of available studies, its safety in the treatment of subdural effusion needs further studies. Therefore, we need to conduct larger randomized controlled studies to fully and accurately address the safety of this approach.

Impact on Glasgow outcome scale

In this meta-analysis, there was no significant difference in GOS ≥ 3 scores between the experimental group and the control group, and early use of elastic bandages could not pass the GOS of patients. GOS is used to assess the long-term functional recovery and prognosis outcomes of patients with brain injuries. A score of ≥ 3 usually indicates that the patient has moderate disability but is able to live independently or recover well [25].It is of great significance to evaluate the condition and prognosis of patients [26]. Three of the studies showed that early pressure dressing with elastic bandages can effectively reduce complications, and another study showed the opposite. The reasons may be as follows: (1) the sample size was too small; (2) the data loss degree was different; (3) The characteristics of the included population were different. There were many complications after decompressive craniectomy. We speculate that elastic bandages mainly reduce fluid accumulation and its related complications (such as infection, space-occupying effect) through physical mechanisms, which may indirectly contribute to improving the overall recovery environment. However, GOS reflects the comprehensive neurological prognosis, which is influenced by multiple factors such as the severity of the initial brain injury, neuroplasticity, and rehabilitation treatment. By applying external pressure, the bandage may prevent the formation or expansion of subdural effusions. This can reduce mass effect on the underlying brain parenchyma, thereby preventing secondary neurological injury from elevated intracranial pressure (ICP) and potentially preserving or improving neurological function. Conversely, improperly applied or excessive pressure could be detrimental. It might increase ICP over a swollen brain, reducing cerebral perfusion pressure (CPP) and leading to ischemia. There was a certain degree of heterogeneity among various studies. Due to certain difficulties in pressure monitoring during pressure dressing of patients, future studies, particularly double-blinded clinical trials, should monitor patients’ dressing pressure. Currently, the optimal pressure measurement, dressing methods, and techniques for compression dressing of elastic bandages are unclear. Bandage compression as a single intervention may not be sufficient to have a significant impact on these core factors that determine the long-term functional outcome.Currently, it is uncertain whether compression dressing with elastic bandages can effectively improve patients’ GOS.

Reduction in hospital stay duration

This meta-analysis elucidated that the early use of elastic bandage pressure dressing can effectively shorten the length of hospital stay [6, 7]. The effectiveness of elastic bandages as a new method to prevent dural effusion after DC has been confirmed, and with proper use, elastic bandages can expedite patients’ recovery and decrease the length of hospital stay. However, it also relies on patients’ specific conditions and treatment plans. Elastic bandages are often used as part of a comprehensive treatment program in conjunction with trepanation or local drainage to achieve better outcomes [27] and accelerate patient discharge time. However, there is a lack of studies on the safety of this approach. This meta-analysis not only confirmed the preventive effect of pressure dressing on the risk of dural effusion after DC but also assessed the safety of this method. Therefore, we suggest that a simple and economical pressure dressing can be applied to prevent dural effusion among patients undergoing DC. Early use of elastic bandage pressure dressing can expedite patients’ discharge, shorten the recovery time, and reduce the burden on patients and families [28].

Limitations and future directions

This meta-analysis has several limitations that should be considered when interpreting the results. First, the methodological quality of the included RCTs was generally moderate. Most studies did not provide sufficient details on randomization and allocation concealment, and none implemented blinding of participants or personnel. These factors may introduce performance and detection bias, potentially overestimating the true intervention effect. Second, significant clinical heterogeneity was observed, stemming from a lack of standardized intervention protocols. The included studies varied considerably in key aspects such as the timing of bandage initiation postoperatively, the amount of pressure applied, the specific wrapping technique, the daily duration of use, and the total treatment period. This variability makes it challenging to pinpoint the optimal application method and limits the clinical applicability of our pooled results.Third, our findings are constrained by a lack of geographic and demographic diversity. All included studies were conducted in a single country (China), which raises concerns about the external validity of our conclusions. The generalizability of these results to other populations with different genetic backgrounds, healthcare systems, baseline risks, and standard postoperative care practices remains uncertain. Fourth, our assessment of safety is incomplete. The included studies primarily focused on efficacy outcomes and did not systematically report on all potential adverse effects. Specifically, the risk of locally increased intracranial pressure or the “blossoming” of cerebral contusions due to external compression—a theoretical concern in patients with a decompressed brain—was not evaluated. Therefore, the medium- and long-term safety profile of this intervention requires further investigation.Krishnan et al. [29] investigated the absorption of subdural effusion with pressure bandage after decompressive craniectomy. Finally, although our sensitivity analysis supported the robustness of the primary outcome, the overall strength of evidence is tempered by the limitations mentioned above. The small number of studies for some outcomes (e.g., adverse events, GOS) also limited the power for those analyses and precluded a meaningful investigation of publication bias using statistical methods.To address these limitations, future research should prioritize large-scale, multinational RCTs that adhere to rigorous methodological standards. These trials should aim to establish standardized protocols for elastic bandage application, including optimal pressure, timing, and duration. Furthermore, future studies must include comprehensive and systematic monitoring of both efficacy and safety outcomes to fully define the risk-benefit profile of this intervention.

Discuss the implications of geographic limitations on external validity and propose ways to broaden future research:①The highest priority is to conduct large-scale, multicenter, and multinational Randomized Controlled Trials (RCTs). Involving centers from diverse geographic regions is the way to establish external validity and produce globally relevant evidence;②We believe that pressure sensors can be used during the compression bandaging process to measure the pressure, ensuring objective and consistent pressure application. Standardized bandaging methods should be adopted to ensure uniform pressure distribution. Meanwhile, the duration of exploratory and clear compression bandaging should be determined and checked daily. Standardized intervention methods should be employed to address heterogeneity issues.In conclusion, based on the available evidence, the early application of elastic bandages may reduce the incidence of subdural effusion and adverse events, and could be associated with a shorter hospital stay for patients after decompressive craniectomy. However, our analysis found no clear evidence that this intervention improves the Glasgow Outcome Scale score. These findings should be interpreted with caution due to the methodological limitations and geographic concentration of the included studies. Future high-quality, multi-center randomized controlled trials are required to confirm the efficacy and safety of early elastic bandages and to establish standardized application protocols.

Abbreviations

DC

Decompressive craniectomy

TBI

Traumatic brain injury

GOS

Glasgow outcome scale

MD

Weighted mean difference

SMD

Standard mean difference

RR

Relative risk

AQP4

Aquaporin-4

ICP

intracranial pressure

CPP

cerebral perfusion pressure

Authors’ contributions

Qianqian Peng was responsible for article retrieval, literature screening, literature quality evaluation, literature data extraction, and article writing. Shengmei Wu provided the idea of topic selection to ensure the reliability of the article. Junjing Hua was responsible for literature retrieval, literature re- screening, literature quality evaluation when there is a dispute by the third author evaluation, literature data extraction. Yanli Hu was responsible for evaluating when there is controversy. Xiandi Wu was responsible for revising the article. Lili Zhang and Ying Lei were responsible for the correction of the article. Jiaqin Wang and Xiaolin Li were responsible for the review. All authors read and approved the final manuscript.

Funding

The authors did not receive support from any organization for the submitted work.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study is a systematic review and pooled analysis. The included data mainly come from the publicly published aggregate data. As this study did not involve direct contact or intervention with the original research participants and all the data used were publicly published, anonymized aggregated information, it was determined by the ethics committee of this institution that no ethical approval was required. If unpublished aggregated data or individual participant data (IPD) are requested from the original author during the research process and provided, we will only use such data after signing an appropriate data sharing/usage agreement and obtaining original ethical approval or confirming original consent to cover secondary analysis when necessary. All received IPDs will undergo de-identification processing immediately upon receipt (removing identifiable information such as name, ID number, and precise address) and will only be used for the purposes of this study. The methodology and analysis plan of this study has been pre-registered in PROSPERO: CRD42024551332 (06/06/2024).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.