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

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 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.

Full text

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
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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. Michaels
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 dHebron,
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 physicians 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.
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