6

Looking to the Future

Christina Master, pediatrician, sports medicine and brain injury medicine specialist at Children’s Hospital of Philadelphia, and professor of Pediatrics and Orthopedic Surgery at the University of Pennsylvania Perelman School of Medicine, offered reflections on the workshop and potential ways forward, including areas the Forum could consider for future work. She noted that sessions and speakers during the workshop highlighted a range of examples regarding the promise and potential of innovations and technology in the prevention, diagnosis, and management of traumatic brain injury (TBI), while highlighting opportunities that remain in implementing such advances to improve the care of patients with TBI. The workshop opened with speakers who discussed the important value that patient engagement brings to improving science. Master remarked that the Forum on Traumatic Brain Injury should consider how to incorporate patients into scientific efforts to ensure that the outcomes generated by the work are meaningful to them, and to continue to build and strengthen provider and care system engagement as well.

Several speakers during the workshop emphasized the concept of designing trials with the end in mind, that is, translation into clinical care with a positive effect on patients. This session specifically highlighted that approval from the U.S. Food and Drug Administration (FDA) is not sufficient to achieve this goal, she said, but rather represents one of many goals in a multistep process. Patient benefit from FDA-approved products, tests, or devices is only realized with successful clinical implementation, and Master encouraged scientists to consider the future stages beyond scientific

discovery, and to be intentional, conscious, and thoughtful in creating successful transitions that foster translation of discoveries to clinical care. The Department of Defense is one organization that has focused on implementation, Master remarked, emphasizing the need to shorten the time between a scientific advance to its integration into clinical care, especially in light of the fact that the evidence has indicated that this process typically takes 17 years.

Sustainable efforts will likely require novel collaborations, potentially with untraditional partners with a wealth of resources, whether data, financial, infrastructure, or expertise, such as the National Football League or the National Highway Traffic Safety Administration, in addition to traditional scientific research funding partners, said Master. The financial considerations regarding health care economics—including insurance reimbursement for current procedural terminology or obtaining new codes—directly affect implementation. She said that funding agencies are often mechanistically oriented toward generating new scientific knowledge, but patient impact only follows clinical translation and scientists should consider how their work fits into this framework. Master underscored that technology and innovation carry both the risk of increasing disparities as well as the promise of the opportunity to address disparities. She noted that the ultimate goal in clinical implementation is behavior change—whether the behavior of patients, physicians, or frontline clinicians, or changes to health system practices—and education alone is insufficient to shift behavior on a large scale. Scientific understanding will not improve patient outcomes in the absence of behavior and practice changes, Master emphasized, and researchers, care providers, patients and families, payers, systems of care, and others throughout the TBI community will need to consider how to achieve such change as scientific discoveries advance.

The broad perspective featured early in the workshop narrowed to a granular view in exploring treatment considerations, Master continued. The forum should consider the level of magnification, as it were, at which needed change can most effectively be accomplished. Complicated TBI and health care landscapes feature numerous barriers to address. She suggested that thoughtful attention be given to novel approaches to multimodal data and large datasets currently being collected, both actively and passively, as well as their implications for prevention, diagnosis, and ultimately treatment of patients with TBI. For scientific advances to be effective, the discoveries must reach the patient, she reiterated. Additionally, the TBI field must consider how best to capitalize on the promise of innovation and technology in the clinical setting in an equitable manner that improves patient outcomes and does not increase disparities. Indeed, the goal of forum members is to improve patient outcomes and determine the means by which to influence outcomes. This workshop highlighted mechanisms

that translate scientific advances to the clinical setting that included clinical guidelines and clinical decision support embedded into the electronic health record, Master noted.

There are many compelling areas for research and innovation to inform prevention, care, and recovery among the range of communities who experience TBI that extend beyond the subset of issues discussed during this workshop, Master noted. Examples of areas for potential future Forum discussions or activities could include development and implementation of innovations addressing long-term TBI recovery, including advances in rehabilitation interventions, disability management, and the concept of TBI management as a chronic condition for some patients and families. Activities that focus on the role of social determinants of health in the experience and recovery from TBI and how it a presents challenges to accessing TBI technology innovation, TBI associated with other types of occupational and sports injuries, particularly outside of professional sports, violence-associated TBI, including substantial intersections of TBI with intimate partner violence, with child abuse, or with the criminal justice system, and further exploration of tools and technologies supporting innovative clinical decision support, wearables, and systems of care for TBI could remain areas for future activity.

Stating the importance of working smarter rather than just harder, Master underscored that the TBI field is not unique, and understanding similarities shared with other fields, such as cardiology, oncology, and stroke in the field of neurology, offers opportunities to learn from others’ challenges and successes and to use and translate these lessons learned to TBI. She emphasized that the National Academies of Sciences, Engineering, and Medicine’s Forum on Traumatic Brain Injury fosters collaborative discussion among otherwise potentially siloed focus areas, which in turn bolsters progress in both research and clinical application. An emphasis on collaboration within the TBI field also enables shared learning from one another’s successes and strengthens efforts to improve patient outcomes. Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) is one such example that offers lessons in the effectiveness of collaborative endeavors, she said, and the forum could consider how to bring together research networks such as TRACK-TBI, CENTER-TBI in Europe, and other networks such as the TBI Model System network¹ with appropriate sectors and stakeholders to most effectively drive forward advances in TBI

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¹ For information on the TRACK-TBI initiative and participating researchers and funders, see https://tracktbi.ucsf.edu/transforming-research-and-clinical-knowledge-tbi (accessed July 31, 2024). For information on CENTER-TBI, see https://www.center-tbi.eu/ and for information on the TBI Model System network, see https://msktc.org/about-model-systems/TBI (both accessed September 24, 2024).

prevention, care, and research. Master underscored that the forum’s workshops and action collaboratives, and the conversations and synergies they foster, all generate opportunities to work collaboratively to substantively improve the lives of patients with TBI.