ArticlePDF Available

Does attendance at the ECTRIMS congress impact on therapeutic decisions in multiple sclerosis care?

Authors:
  • St Michael's Hospital - University of Toronto
  • Roche Farma Spain

Abstract and Figures

Conferences traditionally play an important role in the ongoing medical education of healthcare professionals. We assessed the influence of attending the ECTRIMS congress on therapeutic decision-making in multiple sclerosis (MS) care. A non-interventional, cross-sectional study involving 96 neurologists was conducted. Treatment escalation when therapeutic goals were unmet and management errors related to tolerability and safety scenarios of MS therapies were tested using different case-scenarios. Attendance at ECTRIMS was associated with an increase likelihood of treatment escalation in the presence of clinical progression (cognitive decline) and radiological activity (OR 2.44; 95% CI 1.06–5.82) and lower number of management errors (OR 0.26; 95% CI 0.07–0.98). Attendance at ECTRIMS may facilitate therapeutic decisions and reduction in management errors in MS care.
Content may be subject to copyright.
Short Report
Does attendance at the ECTRIMS congress impact
on therapeutic decisions in multiple sclerosis care?
Gustavo Saposnik ,Jorge Maurino , Angel P Sempere, Maria A Terzaghi, Maria Pia Amato and
Xavier Montalban
Abstract
Conferences traditionally play an important role in the ongoing medical education of healthcare
professionals. We assessed the influence of attending the ECTRIMS congress on therapeutic
decision-making in multiple sclerosis (MS) care. A non-interventional, cross-sectional study involving
96 neurologists was conducted. Treatment escalation when therapeutic goals were unmet and manage-
ment errors related to tolerability and safety scenarios of MS therapies were tested using different
case-scenarios. Attendance at ECTRIMS was associated with an increase likelihood of treatment esca-
lation in the presence of clinical progression (cognitive decline) and radiological activity (OR 2.44; 95%
CI 1.06–5.82) and lower number of management errors (OR 0.26; 95%CI 0.07–0.98). Attendance at
ECTRIMS may facilitate therapeutic decisions and reduction in management errors in MS care.
Keywords: Continuing medical education, management errors, behavioral economics, medical deci-
sions, multiple sclerosis, ECTRIMS
Date received: 11 November 2018; revised 2 February 2019; accepted: 8 February 2019
Introduction
Continuing medical education (CME) is a key part
of postgraduate training for healthcare professionals
(HCP) to gain knowledge that ensures optimal care
and outcomes for patients.
1,2
Medical conferences
traditionally play an important role in the ongoing
medical education of HCP, providing access to
breaking evidence from around the world.
3,4
Making therapeutic decisions in multiple sclerosis
(MS) is becoming increasingly difficult due to the
more complicated risk–benefit spectrum of new
disease-modifying therapies (DMTs).
5,6
The
European Committee for Treatment and Research
in Multiple Sclerosis (ECTRIMS) is a non-profit
organization created in 1985 to promote research
and learning among professionals involved in the
management of people with MS.
7
At the annual
ECTRIMS congress, up to 10,000 participants have
the opportunity to discuss the latest scientific
research. However, limited information is available
on the impact of attending the ECTRIMS congress
on the management of patients with MS. The aim of
this study was to assess the influence of attending
the last ECTRIMS congress on therapeutic decisions
and management errors by applying principles from
behavioral economics.
Methods
A non-interventional, cross-sectional, web-based
study using the Qualtrics platform (http://qualtrics.
com) was conducted (DIScUTIR MS Study).
8,9
The
aim of this study was to evaluate whether neurolo-
gists’ risk preferences were associated with thera-
peutic inertia in MS care. We implemented a novel
approach combining case-vignettes with the assess-
ment of cognitive biases through validated experi-
ments in behavioral economics.
6,9
The application of
these principles may help overcome those barriers
by identifying and increasing awareness about cog-
nitive biases or risk preferences (e.g. overconfi-
dence, tolerance to risk, ambiguity, etc.) that may
lead to suboptimal decisions. A post-hoc analysis
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/
licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as
specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Multiple Sclerosis Journal—
Experimental, Translational
and Clinical
January-March 2019, 1–5
DOI: 10.1177/
2055217319835226
!The Author(s), 2019.
Correspondence to:
Gustavo Saposnik,
Stroke Outcomes and
Decision Neuroscience
Research Unit, St. Michael’s
Hospital, University of
Toronto, 55 Queen St E,
Toronto, ON M5C 1R6,
Canada.
saposnikg@smh.ca
Gustavo Saposnik,
Department of Medicine, St.
Michael’s Hospital, Toronto,
Canada
Li Ka Shing Knowledge
Institute, St. Michael’s
Hospital, Toronto, Canada
Department of Economics,
University of Zurich,
Switzerland
Jorge Maurino,
University of Buenos Aires,
Argentina
Medical Department, Roche
Farma, Madrid, Spain
Angel P Sempere,
Department of Neurology,
Hospital General
Universitario de
Alicante, Spain
using data from the aforementioned study was per-
formed by comparing therapeutic decisions between
participants who attended versus those who did not
attend ECTRIMS (exposure). Practicing neurologists
actively involved in the care of patients with MS
from across Spain were invited to participate in the
study by the Spanish Society of Neurology
(Sociedad Espa~
nola de Neurolog
ıa-SEN).
Participants were exposed to 20 simulated MS
case-scenarios, three standardized surveys, and four
behavioral experiments to assess aversion to risk and
ambiguity (unknown probability of an event). Of the
20 simulated case-scenarios, seven scenarios were
designed to determine the presence of therapeutic
inertia with evidence of recurrent clinical relapses
and radiological progression despite first line thera-
pies. Three case scenarios were designed to assess
the appropriate management of side effects of ther-
apies (e.g. transaminitis, lymphopenia, and gastroin-
testinal side effects). The remaining cases were
designed to learn about physicians’ therapeutic pref-
erences and are not accounted for in this analysis.
Further details of the protocol were published else-
where.
8
Informed consent was obtained from all par-
ticipants and the study was approved by the
institutional review board of the St. Michaels
Hospital (Toronto, Canada).
Study outcomes and definitions
We assessed treatment escalation when therapeutic
goals were unmet (e.g. clinical and radiological evi-
dence of disease progression) as defined in our pre-
vious studies.
8,9
We completed two different
analyses: (i) all case-scenarios and (ii) case-
scenarios having a before and after cognitive testing
(e.g. a Symbol Digit Modalities Test drop from over
60 to 40) showing a progressive cognitive decline
plus evidence of disease progression by magnetic
resonance imaging (e.g. at least five new/enlarging
T2 lesions plus one or more gadolinium-enhancing
T1 lesions).
8,10
The outcome of interest was therapeutic inertia (TI)
defined as a dichotomous variable (present if identi-
fied in at least two case-scenarios) and as a contin-
uous variable (by the TI score defined according to
the number of case-scenarios where participants
exhibited inertia).
9
A higher TI score indicates
higher TI.
Management errors were tested with tolerability and
safety scenarios of DMTs (e.g. transaminitis, lym-
phopenia, and gastrointestinal side effects).
11
Mixed
effects models were used to determine the
association between TI score and TI with indepen-
dent variables. All multivariable analyses were
adjusted for age, level of expertise (specialty, prac-
tice setting, years of practice), and MS patient
volume/week, and reported as odds ratio (OR) and
95%confidence interval (CI).
Results
A total of 96 neurologists were included in the study.
The main characteristics of the study population are
shown in Table 1. The mean (SD) age was 40
(8.5) years and 51 (53.1%) were female
neurologists.
Therapeutic inertia (TI)
Lack of treatment escalation was detected in at least
one case-scenario in 68.8%of participants. The
mean (SD) TI score was 1.5 (1.0).
The multilevel mixed-effects linear regression anal-
ysis revealed that participants who attended
ECTRIMS had significantly lower TI scores (bcoef-
ficient 0.30, 95%CI 0.59 to 0.015; p¼0.039).
The multilevel mixed-effects logistic regression
analysis (TI as a dichotomous outcome) revealed
that participants who attended ECTRIMS had 70%
reduction (not reaching significance) in TI (OR 0.32;
95%CI 0.08–1.31).
Finally, the multivariable mixed effects model for
case-scenarios with progressive cognitive decline
plus radiological activity revealed that attendance
at ECTRIMS was associated with an increased like-
lihood of treatment escalation (OR 2.44; 95%CI
1.06–5.82). There were no differences between
fixed- and random-effects models.
Medical management of side effects of DMTs
One third of neurologists made at least one manage-
ment error, whereas 18.8%made two errors out of
three case-scenarios. The multivariable mixed
effects model revealed the attendance to ECTRIMS
was associated a lower number of management
errors (OR 0.26; 95%CI 0.07–0.98). Figure 1 rep-
resents the predicted probability of management
errors by ECTRIMS attendance after adjustment
for covariates (p-value for interaction ECTRIMS
attendance by management errors: 0.048). There
was no association between participants risk prefer-
ences (e.g. risk aversion and aversion to ambiguity)
with the outcomes of interest.
Maria A Terzaghi,
Li Ka Shing Knowledge
Institute, St. Michael’s
Hospital, Toronto, Canada
Maria Pia Amato,
NEUROFARBA
Department, Neurosciences
Section, University of
Florence, Italy
IRCCS Fondazione Don
Carlo Gnocchi,
Florence, Italy
Xavier Montalban,
Department of Medicine, St.
Michael’s Hospital, Toronto,
Canada
Department of Neurology-
Neuroimmunology, Hospital
Universitari Vall dHebron,
Barcelona, Spain
Multiple Sclerosis Journal—Experimental, Translational and Clinical
2 www.sagepub.com/msjetc
Discussion
CME is especially relevant due to rapidly evolving
knowledge and is a required element of maintenance
of certification in most countries.
2,4
CME has a pos-
itive impact on physicians knowledge and perfor-
mance.
3
We found that participants who attended
ECTRIMS were 2.5 times more likely to escalate
treatment when there was evidence of disease activ-
ity and had a significant lower TI and lower number
of management errors.
Previous studies found that didactic sessions did
not appear to be effective in changing physician
performance in a review of 14 randomized con-
trolled studies of formal educational interventions
including conferences, meetings, and symposia.
12
Later on, Forsetlund et al. examined the effects of
continuing education meetings on professional
practice and patient outcomes.
13
They reviewed
81 trials involving more than 11,000 HCP and
found that higher attendance at educational meet-
ings was associated with larger improvements in
clinical practice. However, educational meetings
did not appear to be effective for complex behav-
iors compared to less complex behaviors as well as
less effective for less severe outcomes than for
more serious ones.
13
CME has evolved from a passive, traditional didactic
approach to an interactive earner-centered approach
involving new technologies. HCP can now get faster
access to the information they need.
2
Unfortunately,
little data are available about effective educational
interventions that target neurologists.
1
Our study has several limitations that deserve com-
ment. First, we included neurologists only from
Spain, limiting the generalizability of our results.
Second, we cannot rule out the role of unmeasured
confounders (e.g. infrastructure of centers, differen-
ces in previous medical education, previous partici-
pation in different MS/general neurology
conferences and/or CME resources other than
ECTRIMS) and possible selection bias to explain
our findings. Third, it is possible the presence of
residual confounding despite the adjustment for rel-
evant factors and differences in baseline character-
istics. Finally, durability of the educational effect of
attending this medical conference should be ana-
lyzed in future studies.
Table 1. Baseline characteristics of participants.
Characteristics
Total
n¼96
Attendees
at ECTRIMS
n¼56
Non-attendees
n¼40 p-value
Age (mean SD), in years 39.5 8.5 39.8 8.5 39.3 8.6 0.78
Age >40, in years 56 (58.3) 24 (42.9) 32 (57.1) 0.83
Gender, n(%)
Female 51 (53.1) 32 (57.1) 19 (47.5) 0.35
MS expertise, n(%) 0.003
General neurologist 32 (33.3) 12 (21.4) 20 (50.0)
MS specialist 64 (66.7) 44 (78.6) 20 (50.0)
Practice setting, n(%) 0.56
Academic 69 (71.9) 39 (69.6) 30 (75.0)
Community 27 (27.1) 17 (30.4) 10 (25)
Years in practice, mean SD 14.1 10 14.8 11 13.1 8 0.41
MS patients seen per week, mean SD 20 15 22.8 21 15.2 13 0.05
Author of a peer-reviewed publication
in the last 3 years, n(%)
79 (82.3) 49 (87.5) 30 (75.0) 0.11
Participants’ risk preferences
Risk aversion
a
26 (27.1) 17 (30.4) 9 (22.5) 0.39
Aversion to ambiguity
b
26 (27.1) 15 (26.8) 11 (27.5) 0.94
Numbers between brackets represent percentages, unless otherwise specified.
a
Participants choose a safe amount of 120 euros or less instead of a 50/50 chance of winning 400 euros.
b
Participants choose the 50/50 known probability of winning 400 euros over the unknown probability of winning 400
euros. Further details are explained elsewhere.
8
Saposnik et al.
www.sagepub.com/msjetc 3
Our study suggests that attendance at ECTRIMS
(the most well attended CME in the specialty) is
associated with improved therapeutic decisions and
reduction in management errors, confirming the pos-
itive role of CME to foster physicians’ knowledge
and performance.
Conclusion
ECTRIMS and possibly the attendance at other med-
ical conferences may play a role as a complementary
strategy to optimize long-term learning of neurolo-
gists that may facilitate therapeutic decisions and
reduction in management errors in MS care.
Acknowledgements
The authors are most grateful to all physicians who par-
ticipated in the study.
Conflict of Interests
The author(s) declared the following potential conflicts of
interest with respect to the research, authorship, and/or
publication of this article: MPA received research grants
and honoraria as a speaker and is a member of advisory
boards for Bayer, Biogen, Merck, Novartis, Sanofi
Genzyme, Teva, Almirall, and Roche. JM is an employee
of Roche Farma, Spain. XM received speaking honoraria
and travel expenses for scientific meetings or participated
in steering committees or in advisory boards for clinical
trials with Almirall, Bayer, Schering Pharma, Biogen,
Genentech, Genzyme, GSK, Merck Serono, MS
International Federation, National Multiple Sclerosis
Society, Novartis, Roche, Sanofi Genzyme, and Teva.
APS received compensation for serving on scientific advi-
sory boards or in speaker’s bureaus from Biogen, Bayer,
Merck, Novartis, Roche, Sanofi Genzyme, and Teva. GS is
supported by the Heart and Stroke Foundation Career
Award following an open peer reviewed advertisement.
He has also received compensation from Amgen
and Roche.
Funding
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publication of
this article: This work was sponsored by the Spanish
Society of Neurology (SEN) and partially funded by an
operating grant from Roche Spain.
ORCID iD
Gustavo Saposnik http://orcid.org/0000-0002-5950-
9886
Jorge Maurino http://orcid.org/0000-0001-9858-3555
-1 01 2
number of errors
-1 01 2
number of errors
-1 0 1 2
number of errors
0.5 11.5
Predict ed probability of ME
0.5 11.5
Predict ed probability of ME
0.5 11.5
Predict ed probability of ME
Non-attendees to ECTRIMS Attendees to ECTRIMS
Total
95% CI Fitted values
p-value for interacon (errors by ECTRIMS
aendance): 0.048
Figure 1. Predicted number of management errors (ME) by ECTRIMS attendance. Note differences in the slope of ME between attendees vs.
non-attendees (p¼0.048).
Multiple Sclerosis Journal—Experimental, Translational and Clinical
4 www.sagepub.com/msjetc
Note
The abstract of this paper was presented at the 34
th
Congress of the European Committee for Treatment and
Research in Multiple Sclerosis (ECTRIMS) as an eposter
presentation with interim findings.
References
1. Khazanova D and Safdieh JE. Continuing medical
education in neurology. Semin Neurol 2018;
38: 479–485.
2. Asch DA and Weinstein DF. Innovation in medical
education. N Engl J Med 2017; 371: 794–795.
3. Cervero RM and Gaines JK. The impact of CME on
physician performance and patient health outcomes:
an updated synthesis of systematic reviews. J Contin
Educ Health Prof 2015; 35: 131–138.
4. Peck C, McCall M, McLaren B, et al. Continuing
medical education and continuing professional devel-
opment: international comparisons. BMJ 2000;
320: 432–435.
5. Comi G, Radaelli M, Soelberg Sørensen P. Evolving
concepts in the treatment of relapsing multiple sclero-
sis. Lancet 2017; 389: 1347–1356.
6. Saposnik G and Montalban X. Therapeutic inertia in
the new landscape of multiple sclerosis care. Front
Neurol 2018; 9: 174.
7. ECTRIMS. Mission and goals, www.ectrims.eu/mis
sion-vision-goals/ (2018, accessed November 2018).
8. Saposnik G, Sempere AP, Raptis R, et al. Decision
making under uncertainty, therapeutic inertia, and
physicians’ risk preferences in the management of
multiple sclerosis (DIScUTIR MS). BMC Neurol
2016; 16: 58.
9. Saposnik G, Sempere AP, Prefasi D, et al. Decision-
making in multiple sclerosis: the role of aversion to
ambiguity for therapeutic inertia among neurologists
(DIScUTIR MS). Front Neurol 2017; 8: 65.
10. Benedict RH, DeLuca J, Phillips G, et al. Validity of
the Symbol Digit Modalities Test as a cognition per-
formance outcome measure for multiple sclerosis.
Mult Scler 2017; 23: 721–733.
11. Soelberg Sørensen P. Safety concerns and risk man-
agement of multiple sclerosis therapies. Acta Neurol
Scand 2017; 136: 168–186.
12. Davis D, Thomson O’Brien MA, Freemantle N, et al.
Impact of formal continuing medical education: do
conferences, workshops, rounds, and other traditional
continuing education activities change physician
behavior or health outcomes? JAMA 1999;
282: 867–874.
13. Forsetlund L, Bjørndal A, Jamtvedt G, et al.
Continuing education meetings and workshops:
effects on professional practice and health care out-
comes. Cochrane Database Syst Rev 2009;
2: CD003030.
Saposnik et al.
www.sagepub.com/msjetc 5
Article
Observational studies investigate a wide range of topics in multiple sclerosis research. This paper presents an overview of the various observational designs and their applications in clinical studies. Observational studies are well suited for making discoveries and assessing new explanations of phenomena, but less so for establishing causal relationships, due to confounding by indication (selection bias), co-morbidity, socio-economic or other factors. Whether observational findings are demonstrative, indicative or only suggestive, depends on the research question, whether and how the design fits this question, analytical techniques, and the quality of data. Observational studies may be cross-sectional vs. longitudinal, and prospective vs. retrospective. The term ‘retrograde’ is proposed to explicate that cross-sectional studies may obtain data that cover (long) preceding periods. Case reports and case series are usually based on accidental observations or routinely collected data. Cross-sectional studies, by simultaneously assessing clinical phenomena and external factors, enable the discovery and quantification of associations. In ecological studies the unit of analysis is population or group, and relationships on patient level cannot be established. A cohort study is a longitudinal study that investigates patients with a defining characteristic, e.g. diagnosis or specific treatment, by analyzing data acquired at various intervals. Prospective cohort studies use (some) data that are not yet available at the time the research is conceived, whereas in retrospective studies the data already exist. In a case-control study a representative group of patients with a specific clinical feature is compared with controls, and the frequencies at which an external factor, e.g. infection, has occurred in each group is compared; in a nested case-control study controls are drawn from a fully known cohort. Randomized controlled trial (RCT)-extension studies are informative because, due to RCT randomization, they are free from confounding by indication. Patient or disease registries are organised systems for the long-term collection of uniform data on a population that is defined by a particular disease, condition or exposure, with the purpose to study changes over time. In pharmacotherapeutic research, accidental observations of unexpected beneficial effects may lead to further research into a drug's efficacy in other conditions. Uncontrolled phase 1 studies investigate safety and dosing aspects. Observational studies are alternatives to RCTs when these are not feasible for ethical or practical reasons. Phase 4 observational studies play a crucial role in the evaluation of the effectiveness of treatments in daily practice, the validation of RCT-based side effect profiles, and the discovery of late occurring or rare, potentially life-threatening side effects. Combinations of multidisciplinary longitudinal data bases into large data sets enable the development of algorithms for personalized treatments. To improve the reporting of observational findings on treatment effectiveness, it is proposed that abstracts define the research question(s) the study was meant to answer, study design and analytical methods, and identify and quantify the patient population, treatment of interest, relevant outcomes and the study's strengths and limitations. The development of guidelines for Strengthening the Reporting of Observational Studies in Effectiveness Research (STROBER), as an extension of the guidelines used in epidemiology, is wanted.
Article
Full-text available
The landscape of multiple sclerosis (MS) treatment is constantly changing. Significant heterogeneity exists in the efficacy and risks associated with these therapies. Therefore, clinicians have the challenge to tailor treatment based on several factors (disease activity level, risk of progression, individual patient preferences and characteristics, personal expertise, etc.), to identify the optimal balance between safety and efficacy. However, most clinicians have limited education in decision-making and formal training in risk management. Together, these factors may lead to therapeutic inertia (TI); defined as the absence of treatment initiation or intensification when therapeutic goals are unmet. TI may lead to suboptimal treatments choices, worse clinical outcomes, and more disability. This article provides a succinct overview on factors influencing TI in MS care.
Article
Full-text available
Objectives Limited information is available on physician-related factors influencing therapeutic inertia (TI) in multiple sclerosis (MS). Our aim was to evaluate whether physicians’ risk preferences are associated with TI in MS care, by applying concepts from behavioral economics. Design In this cross-sectional study, participants answered questions regarding the management of 20 MS case scenarios, completed 3 surveys, and 4 experimental paradigms based on behavioral economics. Surveys and experiments included standardized measures of aversion ambiguity in financial and health domains, physicians’ reactions to uncertainty in patient care, and questions related to risk preferences in different domains. The primary outcome was TI when physicians faced a need for escalating therapy based on clinical (new relapse) and magnetic resonance imaging activity while patients were on a disease-modifying agent. Results Of 161 neurologists who were invited to participate in the project, 136 cooperated with the study (cooperation rate 84.5%) and 96 completed the survey (response rate: 60%). TI was present in 68.8% of participants. Similar results were observed for definitions of TI based on modified Rio or clinical progression. Aversion to ambiguity was associated with higher prevalence of TI (86.4% with high aversion to ambiguity vs. 63.5% with lower or no aversion to ambiguity; p = 0.042). In multivariate analyses, high aversion to ambiguity was the strongest predictor of TI (OR 7.39; 95%CI 1.40–38.9), followed by low tolerance to uncertainty (OR 3.47; 95%CI 1.18–10.2). Conclusion TI is a common phenomenon affecting nearly 7 out of 10 physicians caring for MS patients. Higher prevalence of TI was associated with physician’s strong aversion to ambiguity and low tolerance of uncertainty.
Article
Full-text available
Cognitive and motor performance measures are commonly employed in multiple sclerosis (MS) research, particularly when the purpose is to determine the efficacy of treatment. The increasing focus of new therapies on slowing progression or reversing neurological disability makes the utilization of sensitive, reproducible, and valid measures essential. Processing speed is a basic elemental cognitive function that likely influences downstream processes such as memory. The Multiple Sclerosis Outcome Assessments Consortium (MSOAC) includes representatives from advocacy organizations, Food and Drug Administration (FDA), European Medicines Agency (EMA), National Institute of Neurological Disorders and Stroke (NINDS), academic institutions, and industry partners along with persons living with MS. Among the MSOAC goals is acceptance and qualification by regulators of performance outcomes that are highly reliable and valid, practical, cost-effective, and meaningful to persons with MS. A critical step for these neuroperformance metrics is elucidation of clinically relevant benchmarks, well-defined degrees of disability, and gradients of change that are deemed clinically meaningful. This topical review provides an overview of research on one particular cognitive measure, the Symbol Digit Modalities Test (SDMT), recognized as being particularly sensitive to slowed processing of information that is commonly seen in MS. The research in MS clearly supports the reliability and validity of this test and recently has supported a responder definition of SDMT change approximating 4 points or 10% in magnitude.
Article
Full-text available
Background The management of multiple sclerosis (MS) is rapidly changing by the introduction of new and more effective disease-modifying agents. The importance of risk stratification was confirmed by results on disease progression predicted by different risk score systems. Despite these advances, we know very little about medical decisions under uncertainty in the management of MS. The goal of this study is to i) identify whether overconfidence, tolerance to risk/uncertainty, herding influence medical decisions, and ii) to evaluate the frequency of therapeutic inertia (defined as lack of treatment initiation or intensification in patients not at goals of care) and its predisposing factors in the management of MS. Methods/Design This is a prospective study comprising a combination of case-vignettes and surveys and experiments from Neuroeconomics/behavioral economics to identify cognitive distortions associated with medical decisions and therapeutic inertia. Participants include MS fellows and MS experts from across Spain. Each participant will receive an individual link using Qualtrics platform© that includes 20 case-vignettes, 3 surveys, and 4 behavioral experiments. The total time for completing the study is approximately 30–35 min. Case vignettes were selected to be representative of common clinical encounters in MS practice. Surveys and experiments include standardized test to measure overconfidence, aversion to risk and ambiguity, herding (following colleague’s suggestions even when not supported by the evidence), physicians’ reactions to uncertainty, and questions from the Socio-Economic Panel Study (SOEP) related to risk preferences in different domains. By applying three different MS score criteria (modified Rio, EMA, Prosperini’s scheme) we take into account physicians’ differences in escalating therapy when evaluating medical decisions across case-vignettes. Conclusions The present study applies an innovative approach by combining tools to assess medical decisions with experiments from Neuroeconomics that applies to common scenarios in MS care. Our results will help advance the field by providing a better understanding on the influence of cognitive factors (e.g., overconfidence, aversion to risk and uncertainty, herding) on medical decisions and therapeutic inertia in the management of MS which could lead to better outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0577-4) contains supplementary material, which is available to authorized users.
Article
Continuing medical education (CME) is designed to keep physicians up-to-date on ever-changing practices and guidelines to provide patients with high quality care. CME is especially important in the field of neurology due to rapidly evolving knowledge and medical advances, and is a required element of maintenance of certification. CME itself has evolved from a passive, didactic approach to a learner-centered approach which utilizes new technologies, online learning, and simulations. CME improves knowledge, skills, and, to a lesser extent, patient outcomes, with multimodal, interactive interventions found to be most effective in teaching health care professionals. However, little data are available on CME in neurology. There is a significant gap in knowledge about CME interventions that work for neurologists. Rigorous education research, as well as making effective CME interventions more readily available to neurologists, is critical to optimize lifelong learning of physicians in the field of neurology.
Article
Currently, more than ten drugs have been approved for treatment of relapsing-remitting multiple sclerosis (MS). Newer treatments may be more effective, but have less favorable safety record. Interferon-β preparations and glatiramer acetate treatment require frequent subcutaneous or intramuscular injections and are only moderately effective, but have very rarely life-threatening adverse effects, whereas teriflunomide and dimethyl fumarate are administered orally and have equal or better efficacy, but have more potentially severe adverse effects. The highly effective therapies fingolimod, natalizumab, daclizumab, and alemtuzumab have more serious adverse effects, some of which may be life-threatening. The choice between drugs should be based on a benefit-risk evaluation and tailored to the individual patient's requirements in a dialogue between the patient and treating neurologist. Patients with average disease activity can choose between dimethyl fumarate and teriflunomide or the "old injectable." Patients with very active MS may choose a more effective drug as the initial treatment. In case of side effects on one drug, switch to another drug can be tried. Suboptimal effect of the first drug indicates escalation to a highly efficacious drug. A favorable benefit-risk balance can be maintained by appropriate patient selection and appropriate risk management on therapy. New treatments will within the coming 1-2 years change our current treatment algorithm for relapsing-remitting MS.
Article
In the past 20 years the treatment scenario of multiple sclerosis has radically changed. The increasing availability of effective disease-modifying therapies has shifted the aim of therapeutic interventions from a reduction in relapses and disability accrual, to the absence of any sign of clinical or MRI activity. The choice for therapy is increasingly complex and should be driven by an appropriate knowledge of the mechanisms of action of the different drugs and of their risk-benefit profile. Because the relapsing phase of the disease is characterised by inflammation, treatment should be started as early as possible and aim to re-establish the normal complex interactions in the immune system. Before starting a treatment, neurologists should carefully consider the state of the disease, its prognostic factors and comorbidities, the patient's response to previous treatments, and whether the patient is likely to accept treatment-related risks in order to maximise benefits and minimise risks. Early detection of suboptimum responders, thanks to accurate clinical monitoring, will allow clinicians to redesign treatment strategies where necessary.
Article
Since 1977, many systematic reviews have asked 2 fundamental questions: (1) Does CME improve physician performance and patient health outcomes? and (2) What are the mechanisms of action that lead to positive changes in these outcomes? The article's purpose is to synthesize the systematic review literature about CME effectiveness published since 2003. We identified 8 systematic reviews of CME effectiveness published since 2003 in which primary research studies in CME were reviewed and physicians' performance and/or patient health outcomes were included as outcome measures. Five systematic reviews addressed the question of "Is CME Effective?" using primary studies employing randomized controlled trials (RCTs) or experimental design methods and concluded: (1) CME does improve physician performance and patient health outcomes, and (2) CME has a more reliably positive impact on physician performance than on patient health outcomes. The 8 systematic reviews support previous research showing CME activities that are more interactive, use more methods, involve multiple exposures, are longer, and are focused on outcomes that are considered important by physicians lead to more positive outcomes. Future research on CME effectiveness must take account of the wider social, political, and organizational factors that play a role in physician performance and patient health outcomes. We now have 39 systematic reviews that present an evidence-based approach to designing CME that is more likely to improve physician performance and patient health outcomes. These insights from the scientific study of CME effectiveness should be incorporated in ongoing efforts to reform systems of CME and health care delivery. © 2015 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.
Article
On July 29, 2014, the Institute of Medicine (IOM) released its report on the governance and financing of graduate medical education (GME).(1) An important incidental finding of the IOM's study was that the evidence base available to inform future directions for the substance, organization, and financing of GME is quite limited. The limited evidence reflects a systematic lack of research investment in an area of health care that we believe deserves better. Our nation's lack of research in medical education contrasts starkly with the large and essential commitment to biomedical research funded by industry, philanthropic organizations, and the public. No . . .