Clinical Practice in the USA

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Tornatore et al. Practice patterns of US neurologists in patients with CIS, RRMS, or RIS: A consensus study Neurol Clin Pract March 2012 2:48-57
We assess current practice patterns of US neurologists in MSers with clinically isolated syndrome (CIS), relapsing-remitting multiple sclerosis (RRMS), and radiologically isolated syndrome (RIS) using case-based surveys. For CIS, 87% recommended initiation of disease-modifying therapy (DMT) with MRI brain lesions. An injectable DMT was recommended by 90%–98% for treatment-naive, mild RRMS patients. There was 97% consensus to treat highly active RRMS, but no consensus on therapy choice. With RIS, there was consensus not to initiate treatment with brain but no spinal MRI lesions. Current US treatment patterns emphasize MRI in MS diagnosis and subsequent treatment decisions, treatment of early disease, aggressive initial treatment of highly active MS, and close MSer monitoring.

Khan et al. Practice patterns of US neurologists in patients with SPMS and PPMS:A consensus study Neurol Clin Pract March 2012 2:58-66
A modified Delphi process assessed current multiple sclerosis (MS) practice patterns for secondary and primary progressive MS (secondary progressive MS [SPMS] and primary progressive MS [PPMS]). In early 2011, 2 sequential, case-based surveys were administered to 75 US MS specialists to assess treatment practices and patient management. Respondents were from geographically diverse US academic (42%) and community (58%) treatment centers. There was consensus (≥75% agreement in responses) to switch disease-modifying therapies for an MSer with SPMS with both MRI activity and disability progression (95%), but no consensus on treatment selection. For PPMS, responses supported diagnosis using spinal MRI (100%) and lumbar puncture (75%) and treatment initiation in patients with brain gadolinium-enhancing lesions with or without spinal cord lesions (85%); however, there was no consensus on treatment initiation with spinal cord lesions alone or initial therapy. The lack of agreement among US MS experts on the best treatment approaches for SPMS or PPMS highlights the need for effective therapies

“Although we are based in the UK, many of our readers are based in the USA, hence this post. In the UK we are not able to prescribe DMTs so liberally. Our current guidelines don’t allow us to use DMTs in CIS and we can only use them in a minority of MSers with RRMS. A person with RRMS has to fulfil contemporary criteria for having active disease, i.e. two significant attacks in a 2 year period.  Finally, we can only prescribe natalizumab, and now fingolimod, for MSers with highly active relapsing MS: two disabling attacks in a 12 month period with MRI evidence of active disease (new lesions or Gd-enhancing lesions). These factors, and the fact that UK MSologists are more conservative than US MSologists, explains the low rate of DMT penetration in the UK compared to the US. In the UK less than 1 in 4 MSers are on a DMT compared to over 3 in 4 MSers in the US. Are we being too conservative?”

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

8 comments

Leave a Reply to Jaqulin Farnandez Cancel reply

  • Simple – it is no rocket science. UK has no money in its coffers.

    Most of Europe is being turned into a socialist bloc of real estate. Why is anyone surprised ? Obama will make sure that USA is headed in that direction too. Its OK to be poor but to demand the 'best care' as they do it in the US is ridiculous. How can one be poor and demanding ?

    AJR

  • I agree; socialism is failing miserably. Like communism it is time to dismantle it. The sooner the NHS is privatised the better. At least standards will rise. I am sick and tired of receiving poor quality shoddy services from a second, or third, rate institutions. I just wish the British public would wake up to the fact that the NHS is not delivering.

    • Well well, I'm used to seeing the posts of swivel-eyed right wingers on other blog sites but it's a new phenomenon here. The NHS is one of the greatest achievements in the UK and I'm proud of it and the fact it was set up by one of my fellow countrymen. It's not perfect but it's better than the alternatives. A strategy of the devil take the hindmost simply will not do. I'm sure the vast majority will agree.

    • But the standards in the NHS are so poor. Why not let the NHS create a health credit card and let the population spend it in the private sector where the efficiency and quality will be better. Why should we have to wait for access to care? It will also improve the economics of the NHS and will cause failing institutions to close and successful ones to expand and innovate. There is nothing like raw capitalism to make things better. The problem with socialism is that it is a big drag on quality and innovation, not to mention its effect on morale!

    • Why would you want to spend more in the private sector (who need to up share price and dividends to investors) than you would in the NHS for what is usually exactly the same service.
      All the private companies want to do is leech off the NHS and perform the simple stuff whilst leaving the more complicated to the NHS.
      Remember if you have a bad event in private facilities the vast majority of time you're straight into an NHS ITU pronto.

  • No way should the NHS be privatised. It does deliver in most cases, although the post code lottery is a problem. The alternative of health insurance as in the US would leave the poor and the chronically sick without treatment. Also the NHS is a big spender when it comes to dealing with pharma, and so has more clout compared to individual insurance cos. We need the guidelines modified in the UK to take into account the newer DMTs and an individual MSers needs, not just a tick boxes mentality.

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