Lancet Neurology Commission on TBI
Presented at European Parliament By Andrew I.R. Maas and David K. Menon
20
The Lancet Neurology
Commission on
Traumatic Brain Injury
(TBI) was presented at
the European Parliament
in Brussels on Nov. 7,
2017. The commission
summarizes the state of
the art on epidemiology,
clinical care and research
in traumatic brain injury.
It highlights gaps in our knowledge, disconnects in care pathways,
and sets out new strategies for clinical evidence generation and
implementation. It highlights the importance of international
and transdisciplinary collaborations to reduce the individual and
societal burden of TBI. The commission reflects collaborative
approaches, being authored by over 300 international clinicians
and researchers, many of whom are part of the International
Initiative for Traumatic Brain Injury Research (InTBIR, https://
intbir.nih.gov).
The opening statement of the commission — “A concerted
effort to tackle the global health problem caused by TBI is long
overdue” — is, if anything, an understatement. TBI is a global
health problem of immense proportions, a disease with one of
the highest unmet needs, and historically has been substantially
underfunded compared to other neurological diseases. About
half the world’s population will suffer a TBI over their lifetime.
TBI is estimated to affect 50 million people and cause 1 million
deaths every year. In the 28 countries of the European Union,
approximately 1.5 million people are admitted to the hospital
each year because of TBI, and 56,000 of these will die. Reported
mortality rates in the U.S. appear even higher than in Europe. TBI
is the leading cause of mortality in young adults and a major cause
of disability across all ages.
Substantial recent interest has focused on the health impact of
sports-related concussion and its long-term effects, particularly
repetitive injuries (which may carry increased risks). TBI should
not be seen as an event, but as a process, often with lifelong
consequences. Globally, 50 million survivors live with disability
from TBI, which is progressive in a significant minority, and
TBI also increases the risk of late-life dementia. The care and
consequences of TBI cost the global economy US$400 billion
annually. Given an estimated gross world product of about $74
trillion, this means that about $1 in every $200 of annual global
output is spent on the costs or consequences of TBI.
Increasing industrialization and motor vehicle use are causing
increases in TBI due to traffic incidents in low-income and middleincome
countries, which disproportionately affect the young. In
high-income countries, incidence of TBI is highest and increasing
in the elderly due to falls. Expectations of unfavorable outcomes in
the elderly can lead to treatments being withheld or prematurely
withdrawn, with resulting poorer outcomes reinforcing therapeutic
nihilism in the management of these patients. However, with
appropriate care good results can be obtained.
Advances in the care of patients with TBI are hampered by
inconsistent epidemiological data, poor integration of systems
of care and substantial disparities in access to care. Furthermore,
current medical management is based on a one-size-fits-all
approach, which is inappropriate for such a heterogeneous
disease. Inadequate attention to such heterogeneity at
presentation and outcome might also be a substantial
contributor to the failure of clinical trials of promising new
therapies. Crucially, even when additional evidence is generated
to improve management, the integration of such evidence
into clinical guidelines and routine clinical care is slow. Most
importantly, many cases of TBI are preventable, but well
recognized measures to prevent the disease are not universally
mandated in law or are poorly implemented in practice.
Priorities and recommendations are presented to advance clinical
care and research by identifying strategies to better characterize
TBI, increase prognostic accuracy and match treatments to
patients — a precision medicine approach. The commission
further calls for research approaches to identify best practices
by exploring differences in management and outcome using
comparative effectiveness research. It calls for a move toward
generation and implementation of “living evidence” aiming
to reduce the evidence-practice gap and increase the clinical
relevance of practice recommendations.
The establishment of InTBIR as collaboration of funding agencies
constitutes a substantial step forward toward collaborative research
and data sharing, but these advances need to be consolidated
toward the future and broadened to ensure global participation.
Over 80 percent of TBI occurs in low- and middle-income
countries, but, conversely, over 80 percent of research is conducted
in high-income countries. It is essential that the involvement of
LMICs in evidence generation and development of guidelines is
strengthened.
The Lancet Commission Issue has brought TBI to the foreground
of political attention. It is now up to policymakers, funders
and health care professionals to take the recommendations
summarized in the infographic forward.
Read more: http://www.thelancet.com/commissions/traumaticbrain
injury
Andrew I.R. Maas David K. Menon
