Risk Factors for Suboptimal Medication Adherence in Persons With Multiple Sclerosis: Development of an Electronic Health Record-Based Explanatory Model for Disease-Modifying Therapy Use

Treatment satisfaction with disease-modifying therapy is the only predictor of Adherence among multiple sclerosis patients from Upper Egypt

Despite the proven efficacy of the disease-modifying therapy (DMT) for multiple sclerosis (MS), the rates of non-adherence are frequently high. We aimed to evaluate the rate of non-adherence to the first DMT in Upper Egypt and identify different contributing factors. Out of 310 patients, ninety-seven adult patients with RRMS were recruited from three MS units located in Upper Egypt and were subjected to the following: complete clinical history, expanded disability status score (EDSS), Eight-item Morisky Medication Adherence Scale (MMAS-8), abbreviated Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9), Hamilton depression scale, Fatigue Severity Scale (FSS) and the Pittsburgh Sleep Quality Index (PSQI). According to MMAS-8 scores, 63 (64.9%) of patients were non-adherent to their first DMT. Non-adherent patients are more likely to have longer disease duration (p = 0.002), longer duration on first DMT (p = 0.030), first DMT-start date before 2019 (p = 0.040), and lower treatment satisfaction scores (p = 0.016). However, there was no significant relation with physical disability, depression, fatigue, or sleep quality. On the regression analysis model, a lower treatment satisfaction score was the only predictor of DMT non-adherence (p = 0.012). Despite expanding DMT options, non-adherence among MS patients in Upper Egypt is high. Treatment satisfaction with DMT is the only predictor of adherence among MS patients of Upper Egypt. Adherence and satisfaction with the prescribed DMT should be assessed carefully to maximize DMT benefits.

Preferences and Perspectives of Specialist Multiple Sclerosis Nurses and Patients with Multiple Sclerosis Regarding the New RebiSmart® 3.0 Autoinjector versus Other Assistive Devices

Purpose

RebiSmart® is an electromechanical multidose autoinjector developed for administering subcutaneous interferon beta-1a in patients with multiple sclerosis (pwMS). This online survey aimed to understand MS nurses' and pwMS preferences and perceptions regarding the features of an upgraded version of the RebiSmart device (RebiSmart 3.0) compared to other assistive devices used for multiple sclerosis (MS) therapy.

Patients and Methods

Eligible MS nurses and pwMS from Germany, Italy, and the United Kingdom completed a double-blind, 30-minute online self-administered questionnaire, including a 10-minute video describing the features of RebiSmart 3.0 and its use in administering interferon beta-1a.

Results

In total, 102 participants (MS nurses, n=52; patients, n=50) completed the survey. Overall, 70% respondents found the RebiSmart 3.0 device "very"/"extremely" appealing, 53% were "very"/"extremely" interested in learning more, and 71% stated they would be "very"/"extremely" comfortable using (pwMS) or educating (MS nurses) on it. Among current or recent RebiSmart 2.0 users (vs RebiSmart 2.0 nonusers), 67% (vs 52%) rated RebiSmart 3.0 "very" or "extremely" appealing, 52% (vs 43%) were "very" or "extremely" interested in learning more about the device, and 67% (vs 48%) stated they would be "very" or "extremely" comfortable using the RebiSmart 3.0 device. Respondents ranked customizable injection process (including injection speed, hold time, depth and rotation guide), self-injection process, and hidden needle as the most important self-assistive device features. RebiSmart 3.0 was rated higher than other self-injecting devices on all tested features. Overall, with respect to the top three features, 89% of the MS nurses and 73% of PwMS rated RebiSmart 3.0 "very good" or "excellent". After reviewing the video, 52% respondents had no questions, 67% nurses recommended providing more information on the customizable injection process feature of RebiSmart 3.0 to patients, and 88% nurses considered patient demonstration materials to be the most helpful type of information for them when initiating and educating pwMS on self-assistive devices.

Conclusion

The overall reactions of MS nurses and pwMS to the RebiSmart 3.0 device features were positive. The incremental advances over previous versions of the device as well as in comparison with other currently available assistive devices were welcomed. The MS nurses identified key needs for patient education on the use of the device and the suitable approaches (training videos and educational leaflets) to support MS nurses and pwMS.

Risk Factors for Chronic Prescription Opioid Use in Multiple Sclerosis

OBJECTIVE

To characterize patterns of prescription opioid use among individuals with multiple sclerosis (MS) and identify risk factors associated with chronic use.

DESIGN

Retrospective longitudinal cohort study examining US Department of Veterans Affairs electronic medical record data of Veterans with MS. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable logistic regression was used to identify demographics and medical, mental health, and substance use comorbidities in 2015-2016 associated with chronic prescription opioid use in 2017.

SETTING

US Department of Veterans Affairs, Veteran's Health Administration.

PARTICIPANTS

National sample of Veterans with MS (N=14,974).

MAIN OUTCOME MEASURE

Chronic prescription opioid use (≥90 days).

RESULTS

All types of prescription opioid use declined across the 3 study years (chronic opioid use prevalence=14.6%, 14.0%, and 12.2%, respectively). In multivariable logistic regression, prior chronic opioid use, history of pain condition, paraplegia or hemiplegia, post-traumatic stress disorder, and rural residence were associated with greater risk of chronic prescription opioid use. History of dementia and psychotic disorder were both associated with lower risk of chronic prescription opioid use.

CONCLUSION

Despite reductions over time, chronic prescription opioid use remains common among a substantial minority of Veterans with MS and is associated with multiple biopsychosocial factors that are important for understanding risk for long-term use.

Effect of an educational intervention based on the theory of planned behavior on improving medication adherence in patients with multiple sclerosis treated with injectable disease-modifying drugs: randomized controlled trial

BACKGROUND

Adherence to prescribed treatment in chronic diseases, as occurs in multiple sclerosis (MS), is a critical factor for a successful therapeutic response. This study aimed to investigate the effect of educational program based on Theory of Planned Behavior (TPB) on treatment adherence in patients with multiple sclerosis (MS) receiving injectable immunomodulatory drugs.

METHODS

The present study is an educational randomized controlled trial research that was conducted on 100 patients with MS who had gone to MS clinic in Tehran city (Iran). The samples were randomly assigned to the intervention (N = 50) and control groups (N = 50). Data collection instrument was a researcher-made questionnaire based on TPB. Then, educational program was performed for the intervention group through four educational sessions. After three months, data collection was repeated for the two groups and data were analyzed.

RESULTS

The knowledge and performance of the intervention group on treatment adherence drugs increased from 56.25 ± 20.3 to 78.31 ± 15.57 and 56.22 ± 5.76 to 71.62 ± 12.01 after the education respectively (p < 0.001). The mean of construct of TPB in the intervention group also increased after the intervention (p < 0.05).

CONCLUSION

Applying the TPB model proved is very effective in developing an educational program for patients with MS, to enhance treatment adherence drugs. Besides such programs, follow-up education for controlling and monitoring are highly recommended.

TRIAL REGISTRATION

This trial has been registered at Iranian Registry of Clinical Trials, IRCT20210808052109N1. Prospectively registered at 12-Aug-2021, (12/8/2021) available at: URL: https://en.irct.ir/trial/57994.

Medication adherence to disease-modifying therapies among a cohort of Jordanian patients with relapsing-remitting multiple sclerosis: a multicentre cross-sectional study

OBJECTIVES

To evaluate medication adherence to oral and parenteral disease-modifying therapies (DMTs) and to explore factors associated with medication non-adherence in patients with multiple sclerosis (MS).

METHODS

A cross-sectional multicentre study was conducted among patients with MS. Patients who attended outpatient clinics of neurology departments from three major referral centres were invited to participate in the study. Medication adherence was measured using the Multiple Sclerosis Treatment Adherence Questionnaire.

KEY FINDINGS

A total of 319 patients with MS on DMT were included in the final analyses, their average age was 35 years and more than two-thirds (72.1%) of them were women. The adherent group comprised 46.7% of patients. The results of association analyses showed that factors that were associated with adherence level were female gender (P = 0.034), non-smoking/x-smoking (P = 0.007), school education (P = 0.019), unemployment (P = 0.006), history of previous DMT (P = 0.020), longer previous treatment duration (P = 0.008), and type of current DMT (P = 0.020). Among the non-adherent patients, there were significant differences between oral and parenteral DMT users in the importance of barriers to adherence (P < 0.001). Additionally, the degree of treatment satisfaction was higher in oral users than in parenteral users (P < 0.001).

CONCLUSIONS

The adherence level was quite low. Gender, smoking status, education, employment status, history of previous DMT, previous treatment duration and type of current DMT were associated with medication non-adherence in our patients with MS. These factors should be considered when evaluating medication adherence, and the modifiable factors may represent potential targets for interventions to improve pharmaceutical care planning in patients with MS.

Appointment attendance behaviors in multiple sclerosis: Understanding the factors that differ between no shows, short notice cancellations, and attended appointments

BACKGROUND

There has yet to be an examination of how appointment attendance behaviors in multiple sclerosis (MS) are related to scheduling metrics and certain demographic, clinical, and behavioral factors such as cognitive functioning and personality traits. This study aimed to examine the factors that differ between no shows (NS), short notice cancellations (SNC), and attended appointments.

METHODS

Participants (n = 110) were persons with MS who were enrolled in a larger cross-sectional study, during which they completed a battery of neuropsychological measures. Data about their appointments in three MS-related clinics the year prior to their study evaluation were extracted from the medical record. Bivariate analyses were done, with post-hoc tests conducted with Bonferroni corrections if there was an overall group difference.

RESULTS

A higher number of SNC were noted during the winter, with 22.4% being due to the weather. SNC were also more common on Thursdays, but less frequent during the early morning time slots (7am to 9am). In contrast, NS were associated with lower annual income, weaker healthcare provider relationships, lower self-efficacy, higher levels of neuroticism, depressive symptom severity, and health distress, and greater cognitive difficulties, particularly with prospective memory.

CONCLUSIONS

While SNC are related to clinic structure and situational factors like the weather, NS may be more influenced by behavioral issues, such as difficulty remembering an appointment and high levels of distress. These findings highlight potential targets for reducing the number of missed appointments in the clinic, providing opportunities for improved healthcare efficiency and most importantly health.

Demographic and Clinical Factors Are Associated Wwith Frequent Short-Notice Cancellations in Veterans with Multiple Sclerosis on Disease Modifying Therapies

OBJECTIVES

(1) To identify the rate of short-notice canceled appointments in a large national sample of persons with multiple sclerosis (MS) and (2) examine the demographic and clinical factors associated with frequent cancellations.

DESIGN

Retrospective cross-sectional cohort using electronic health records.

SETTING

Veterans Health Administration.

PARTICIPANTS

Veterans with MS (N=3742) who were part of the Veterans Health Administraiton's MS Center of Excellence Data Repository and (1) had at least one outpatient appointment at the VA in 2013, (2) were alive in 2015, and (3) were prescribed a disease modifying therapy (DMT).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequent short-notice cancellations, defined as >20% of scheduled appointments canceled with less than 24-hour notification over a 24-month period. This threshold was based on the definition of ≤80% for suboptimal treatment adherence. Several demographics and clinical variables were examined as potential explanatory factors.

RESULTS

Approximately 75% (n=2827) had at least 1 short-notice cancellation, with more than 3% (n=117) categorized as frequent cancelers. The odds of frequent cancellations were greater in women (odds ratio [OR], 1.81; P=.004) and among 18- to 44-year-olds (OR, 2.77; P=.004) and 45- to 64-year-olds (OR, 2.49; P=.003) compared to those over 65. The odds were lower among persons who lived <25 miles away (OR, 0.58; P=.043) compared with persons who lived ≥75 miles away and those who had at least 1 emergency department visit (OR, 0.55; P=.012).

CONCLUSIONS

Short-notice cancellations are common in persons with MS, although few have more than 20%. These findings highlight who is at greater risk for frequent cancellation and disruptions in their care. Although additional research is needed, the results provide insights into how clinics may approach handling frequent short-notice cancellations among persons with MS.

Predictors of adherence and persistence to disease-modifying therapies in Multiple Sclerosis

BACKGROUND AND AIMS

In multiple sclerosis (MS), non-adherence/non-persistence is related to suboptimal response to treatment, including disease relapses and the need for more expensive healthcare. The aim of this study was to identify predictors related to adherence to disease modifying therapies (DMTs) in a cohort of Argentinian MS patients.

METHODS

We conducted a cross-sectional study at the National Medical Care Program from Argentina. MS patients with at least one claim for a DMT from 1 January 2017 to 1 October 2017 were identified. A telephone survey was performed to assess clinical and demographic factors. The medication possession ratio (MPR) was used to estimate adherence; MPR <80% defined non-adherence. Associations were studied using a logistic regression model.

RESULTS

Our database included 648 MS patients. A total of 360 patients (60% females, mean age 55.3 years) accepted to participate. Of these, 308 (85.5%) patients were receiving DMT at the time of the survey. Some 198 (63.7%) were receiving injectable therapies. Optimal adherence was 47.7%. Adherence was associated with oral medication [odds ratio (OR) 1.83 95% confidence interval (CI) 1.13-3.00, p = 0.014]. A factor related to oral drugs was higher educational level (OR 2.86 95%CI 1.41-5.81, p = 0.004).

CONCLUSION

This real-world study showed better adherence and persistence on treatment with oral therapies in MS patients in Argentina.

What Biopsychosocial Factors Explain Self-management Behaviors in Multiple Sclerosis? The Role of Demographics, Cognition, Personality, and Psychosocial and Physical Functioning

OBJECTIVES

To examine the biopsychosocial correlates of overall and individual self-management behaviors in persons with multiple sclerosis (MS), including demographics, co-occurring medical diagnoses, cognition, personality traits, and psychosocial and physical functioning as variables.

DESIGN

Prospective cross-sectional cohort study.

SETTING

Community-based comprehensive MS center.

PARTICIPANTS

Adults with MS (n=112) who completed a brief neuropsychological battery that included a self-report survey and performance-based measures of cognitive function.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The MS Self-management Scale-Revised total score was the primary outcome and its 5 subscales (Healthcare Provider Relationship/Communication, Treatment Adherence/Barriers, Social/Family Support, MS Knowledge and Information, Health Maintenance Behaviors) were secondary outcomes.

RESULTS

Disease-modifying therapy usage (β=0.39), social support (β=0.31), subjective prospective memory (β=-0.25), emotional well-being (β=0.20), and histories of diabetes (β=-0.18) and high cholesterol (β=0.15) were significantly associated with overall self-management in a multivariate model. Correlates of individual self-management behaviors are also described.

CONCLUSIONS

The findings provide insights into the biopsychosocial characteristics contributing to the overall and individual self-management behaviors of persons with multiple sclerosis. The next steps will be to evaluate these factors in a clinical intervention.

Age and sex as determinants of treatment decisions in patients with relapsing-remitting MS

BACKGROUND

. Most patients with relapsing-remitting multiple sclerosis (RRMS) are initially treated with moderate efficacy disease-modifying therapies (meDMTs), and only a smaller group of highly active patients are initiated on a high efficacy disease-modifying therapy (heDMT). Real-world data have shown that choosing a heDMT as the initial therapy in highly active RRMS patients is more effective than using a meDMT, and that in patients with breakthrough disease on a meDMT escalation of treatment to a heDMT is more effective than staying on the same or switching to another meDMT. The role of age and sex as determinants for selection of the initial treatment intensity, and for using escalation of treatment intensity in patients with relapse activity on treatment with meDMTs, is only partially known.

METHODS

. We included all Danish patients with RRMS registered in The Danish Multiple Sclerosis Registry who began a DMT since 2014 and stratified the cohort according to sex and age < 40 and ≥ 40 years at first DMT treatment. We studied determinants, with emphasis on age and sex, for the primary choice of therapy, for adherence to the initial therapy and for treatment escalation. Based on existing literature and clinical relevance, we included the following potential confounders in the analyses: DMT efficacy, pre-treatment relapse activity, disease duration, Expanded Disability Status Scale (EDSS) score, and, in a subgroup, MRI activity.

RESULTS

. With all covariates mutually adjusted, patient age was a strong decisive factor for choosing a heDMT with odds ratio 1.69 for starting a heDMT in patients < 40 years compared with patients ≥ 40 years. Men had odds ratio 1.53 for starting with a heDMT compared with women. The odds ratio of heDMT in patients with EDSS > 3 vs ≤ 3 was 3.49, and every additional relapse was associated with increased odds ratio 2.33 for heDMT. Patients were more adherent to the initial heDMTs than to the initial meDMTs. Patients above 40 years were more prone to stay on the initial treatment compared to patients below 40, regardless of whether the initial treatment was meDMT (p<0.001) or heDMT (p=0.008) (covariates mutually adjusted). Relapse activity resulted in escalation of therapy to a heDMT in 67% of patients aged < 40 years (N=273) and in 56% patients aged 40 years or above (N=159) (p=0.008), and younger patients had odds ratio 1.46 of escalating therapy compared to older patients. Male patients were more likely to have treatment escalation to heDMTs than female patients (odds ratio 2.03).

CONCLUSION

. Age and sex appear to be independent determinants for the choice of the initial DMT and for the decision of treatment escalation in patients with breakthrough disease on a meDMT. It is unfortunate, if older age is a factor that make choice of a heDMT more unlikely, as many DMTs seems to be less efficacious in older patients.