Cameron E, Rog D, McDonnell G, Overell J, Pearson O, French DP.
Mult Scler Relat Disord. 2018 Nov 22;27:378-382. doi: 10.1016/j.msard.2018.11.023. [Epub ahead of print]
Disease-modifying therapies (DMTs) reduce the rate of relapse in relapsing-remitting multiple sclerosis (RRMS) (Oh and O’Connor, 2015), and can therefore improve quality of life and lessen the need for relapse management interventions (e.g. steroids, hospitalisation, neuro-rehabilitation). Accordingly, the Association of British Neurologists (ABN) recommends that DMTs should be considered promptly for all individuals with active RRMS (Scolding et al., 2015). Despite this, people with RRMS in the United Kingdom (UK) are prescribed DMTs considerably less frequently than patients in other European countries.
A B S T R A C T
Background: The proportion of people with relapsing-remitting multiple sclerosis prescribed disease modifying treatments (DMTs) in the United Kingdom (UK) is considered low compared with other countries. There are differences in DMT prescription rates between UK nations (England, Wales, Scotland, Northern Ireland). Despite this, there has been little research into decision-making processes and prescribing practices.
Objective: To investigate views and experiences of neurologists prescribing DMTs and MS specialist nurses to identify factors influencing prescribing.
Methods: Semi-structured interviews with 18 consultant neurologists and 16 specialist nurses from diverse settings across the four UK nations. Data were analysed using thematic framework analysis.
Results: Prescribing practices are influenced by organisational prescribing “cultures”, informal “benchmarking” within peer networks, and prior experience with different DMTs. Health professionals differ in their perceptions of benefits and risks of DMTs and personal “thresholds” for discerning relapses and determining eligibility for DMTs. Prescribers in England felt most constrained by guidelines.
Conclusion: To achieve equity in access to DMTs for people with MS eligible for treatment, there is a need for public discussion acknowledging differences in health professionals’ interpretations of “relapses” and guidelines and perceptions of DMTs, variation in organisational prescribing “cultures”, and whether the prevailing culture sufficiently meets patients’ needs.
Semper Veritas; Latin for truth always, is fine and dandy chiseled onto an obelisk, but reality is far from it, and doesn’t factor in our propensity to procrastinate. Because, for all intents and purposes an evidence-based guideline is as close to the truth as we’re likely to get, and yet none of us follow it? Why???
This is what Cameron et al. are trying to decipher. Although, the number of people questioned in the study is small (18 consultant neurologists and 16 specialist nurses), there are certain truism’s in some of the comments made that makes you wonder just who’s fooling whom!
1) Prescribing guidelines and defining relapses– Neurologists in England felt that the NICE prescribing guidelines for disease-modifying drugs were mandatory and felt obliged to follow it. While participants in Scotland, Wales and Northern Ireland knew of their existence and generally prescribed in line with them, but felt that they had more flexibility in prescribing based on regional regulatory authorities. The later tended to quote patient welfare as a priority rather than meeting recommendations based on cost-effectiveness. Moreover, there was confusion over what was felt to be a disabling relapse, leading to individual biases. Specialist nurses, in particular, had emphasised face-to-face examinations in order to identify disabling relapses.
2) Perceived risk and readiness to prescribe – in my opinion the most difficult to influence equitably. The article talks about how some neurologists felt themselves to be ‘active prescribers’, while other were aggressive when needed, or took a more careful measured approach. The major influencing factor was felt to be the risks associated with the therapies, in particular PML, and long-term side effects of chronic immunosuppression. Also, there were doubts over the long-term effectiveness of therapies, more so if the side-effects were more harmful than simply being under-treated.
3) Familiarity and prior experience – how comfortable you are with a particular therapy over others influences what you prescribe. Participation in clinical trials also influenced this in terms of raising confidence levels on prescribing. Positive and negative outcomes of patients, not surprisingly also influenced this.
4) Peer networks and prescribing cultures – like Hogwarts the neurology cliques exist. Having said this shared learning has become an important outlet for these discussions. Peers and local opinion leaders tended to influence prescribing at a local level, whilst multidisciplinary team meetings may maintain the prescribing culture, but equally alleviate concerns over prescribing the more riskier therapies.
Overall, my colleagues overseas have voiced similar opinions. What makes us prescribe in the UK half the amount of MS therapies than elsewhere has not been answered by this work, but I’m guessing that it’s more to do with the lack of neurologists per population size than eschewing Semper Veritas.