Multivariate analyses of factors associated with unemployment in people with multiple sclerosis

Predictors of vocational status among persons with multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a common cause of neurological disability in young to middle-aged adults, resulting in physical, psychosocial, and cognitive impairments. Manifestation of these symptoms during crucial work-life years can greatly influence the ability of persons with (PwMS) to retain employment. It is unknown what factors are most important in leading to work disability, and if/how these different factors interact with each other and result in work disability.

OBJECTIVE

To determine significant predictors of vocational status among PwMS using a structural equation modeling approach.

METHODS

A retrospective chart review identified PwMS at an academic tertiary care hospital. The following data was collected: demographics and disease characteristics, vocational status, physical disability status (Expanded Disability Status Scale, EDSS), fine motor function (Nine Hole Peg Test, NHPT), generalized fatigue (Fatigue Severity Scale, FSS), mood and anxiety symptoms (Hospital Anxiety and Depression Scale, HADS) and cognitive function (Symbol Digit Modalities Test, SDMT). An exploratory structural equation model (SEM) was developed to examine the predictive utility of clinical and psychosocial variables on vocational status after controlling for demographic and disease characteristics. The fit of the model to the data was examined using the comparative fit index (CFI), normal fit index (NFI), root-mean-squared error of approximation (RMSEA), and standardized root mean residual (SRMR).

RESULTS

There were 158 PwMS included in the analysis. The final model demonstrated that SDMT (β = 0.16), EDSS (β = -0.33), and HADS-D (β = -0.23) significantly predicted vocational status (ps < 0.05). It explained 37% of the variance and provided a good fit to the data (χ²(11) = 13.01, p > 0.05, SRMR = 0.055, RMSEA = 0.034, NFI = 0.94, CFI = 0.99.

CONCLUSIONS

Physical disability, depressive symptoms, and reduced information processing affect work-related disability and vocational status among PwMS. Interventions targeting these factors should be prioritized by clinicians.

Earnings among people with multiple sclerosis compared to references, in total and by educational level and type of occupation: a population-based cohort study at different points in time

OBJECTIVES

To investigate earnings among people with multiple sclerosis (PwMS) before and after MS diagnosis compared with people without MS, and if identified differences were associated with educational levels and types of occupations. Furthermore, to assess the proportions on sickness absence (SA) and disability pension (DP) in both groups.

DESIGN

Population-based longitudinal cohort study, 10 years before until 5 years after MS diagnosis.

SETTING

Working-age population using microdata linked from nationwide Swedish registers.

PARTICIPANTS

Residents in Sweden in 2004 aged 30-54 years with MS diagnosed in 2003-2006 (n=2553), and references without MS (n=7584) randomly selected by stratified matching.

OUTCOME MEASURES

Quartiles of earnings were calculated for each study year prior to and following the MS diagnosis. Mean earnings, by educational level and type of occupation, before and after diagnosis were compared using t-tests. Tobit regressions investigated the associations of earnings with individual characteristics. The proportions on SA and/or DP, by educational level and type of occupation, for the diagnosis year and 5 years later were compared.

RESULTS

Differences in earnings between PwMS and references were observed beginning 1 year before diagnosis, and increased thereafter. PwMS had lower mean earnings for the diagnosis year (difference=SEK 28 000, p<0.05), and 5 years after diagnosis, this difference had more than doubled (p<0.05). These differences remained after including educational level and type of occupation. Overall, the earnings of PwMS with university education and/or more qualified occupations were most like their reference peers. The proportions on SA and DP were higher among PwMS than the references.

CONCLUSIONS

The results suggest that the PwMS' earnings are lower than the references' beginning shortly before MS diagnosis, with this gap increasing thereafter. Besides SA and DP, the results indicate that educational level and type of occupation are influential determinants of the large heterogeneity of PwMS' earnings.

Cognitive Dysfunctions and Assessments in Multiple Sclerosis

Cognitive impairment has been reported at all phases and all subtypes of multiple sclerosis. It remains a major cause of neurological disability in young and middle-aged adults suffering from the disease. The severity and type of cognitive impairment varies considerably among individuals and can be observed both in early and in later stages. The areas which have commonly shown more deficits are: information processing speed, complex attention, memory, and executive function. Even though an alteration in both the white matter and in the gray matter has been found in patients with multiple sclerosis and cognitive impairment, the underlying process still remains unknown. Standardized neurological examinations fail to detect emerging cognitive deficits and self-reported cognitive complaints by the patients can be confounded by other subjective symptoms. This review is a comprehensive and short update of the literature on cognitive dysfunctions, the possible confounders and the impact of quality of life in patients with multiple sclerosis.

Employment and Gainful Earnings Among Those With Multiple Sclerosis

OBJECTIVE

To identify demographic, educational, and disease-related characteristics associated with the odds of employment and earnings among participants with multiple sclerosis (MS).

DESIGN

Cross-sectional using self-report assessment obtained by mail or online.

SETTING

Medical university in the southeastern United States.

PARTICIPANTS

Participants with MS (N=1059) were enrolled from a specialty hospital in the southeastern United States. All were adults younger than 65 years at the time of assessment.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Current employment status and earnings.

RESULTS

MS factors were highly related to employment, yet not as strongly to conditional earnings. Those with no symptoms reported 6.25 greater odds of employment than those with severe current symptoms. Compared with those with progressive MS, those with relapsing or remitting had greater odds of employment (odds ratio [OR]=2.24). Participants with no perceived cognitive impairment had 1.83 greater odds of employment than those with moderate to severe perceived cognitive impairment. Those with <10 years since MS diagnosis had 2.74 greater odds of employment compared with those with >20 years since diagnosis. An absence of problematic fatigue was highly related to the probability of employment (OR=5.01) and higher conditional earnings ($14,454), whereas the remaining MS variables were unrelated to conditional earnings. For non-MS variables, education was highly related to employment status and conditional earnings, because those with a postgraduate degree had 2.87 greater odds of employment and $44,346 greater conditional earnings than those with no more than a high school certificate. Non-Hispanic whites had 2.22 greater odds of employment and $16,118 greater conditional earnings than non-Hispanic blacks, and men reported $30,730 more in conditional earnings than women.

CONCLUSIONS

MS indicators were significantly associated with employment status including time since diagnosis, fatigue, symptom severity, and presence of cognitive impairment. However, among those who were employed, conditional earnings were less highly related to these factors and more highly related to educational attainment.

Prevalence and factors leading to unemployment in MS (multiple sclerosis) patients undergoing immunomodulatory treatment in Poland

Multiple Sclerosis (MS) is the most common, primary neurogenic cause of disability among young adults. We investigated demographic and clinical factors associated with unemployment on the example of 150 MS patients receiving immunomodulatory treatment in Poland. This study was based on clinical evaluation and collection of self-reported questionnaires, with an attention to self-motivation, severe fatigue and moderate disability. Patients who were unemployed (40% of all patients) had a mean disease duration of almost 5 years. Older (p<0.001), less educated (p = 0.007) and more severely disabled patients (p<0,001) were most likely to be unemployed. Moderate disability (OR = 11.089 95% CI: 4.11-34.201, p<0,001), severe fatigue (OR = 2.625 95% CI: 1.02-6.901, p = 0,046) and lower level of self-motivation (KNS) (OR = 0.947, 95% CI: 0.896-0.006, p = 0.042) were independently associated with unemployment.

How does work disability of patients with MS develop before and after diagnosis? A nationwide cohort study with a reference group

OBJECTIVES

We compared work disability of patients with multiple sclerosis (MS) from 5 years before with 5 years after diagnosis, with that of matched controls, and analysed whether progression in work disability among patients with MS was associated with sociodemography.

DESIGN

Population-based cohort study.

SETTING

The adult Swedish general population.

PARTICIPANTS

Residents aged 24-57 diagnosed with MS (n=3685) in 2003-2006 and 18 425 matched controls without MS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual net days of sickness absence (SA) and disability pension (DP), used as a proxy for work disability, followed from 5 years before to 5 years after diagnosis (ie, T-5-T+5). For patients with MS, regression was used to identify sociodemographic factors related to progression in work disability.

RESULTS

Work disability of patients with MS increased gradually between T-5 and T-1 (mean: 46-82 days) followed by a sharp increase (T+1, 142 days), after which only a marginal increase was observed (T+5, 149 days). The matched controls had less work disability, slightly increasing during the period to a maximum of ∼40 days. Men with MS had a sharper increase in work disability before diagnosis. High educational level was associated with less progression in work disability before and around diagnosis.

CONCLUSIONS

Patients with MS had more work disability days also 5 years before diagnosis. Several sociodemographic variables were associated with the absolute level and the progression in SA and DP.

The impact of adjusted work conditions and disease-modifying drugs on work ability in multiple sclerosis

Background:

Multiple sclerosis (MS) is a neurological disorder that causes significantly reduced ability to work, and the Expanded Disability Status Scale (EDSS) is one of the main predictors for reduced work ability.

Objectives:

To investigate how work requirements, flexible work conditions and disease-modifying drugs (DMDs) influence the work ability in relation to different EDSS grades in two MS populations.

Methods:

Work ability was studied in two MS populations: one in the southern and one in the northern part of Sweden, both demographically similar. In the latter population, more active work-promoting interventions have been practised and second-generation DMDs have been widely used from the onset of disease for several years.

Results:

The proportion of MS patients who participated in the workforce or studied was significantly higher in the northern compared with the southern population ( p < 0.001). The employees in the northern population had significantly lower requirements, greater adapted work conditions and were able to work more hours per week. Higher EDSS was associated with lower reduction in number of worked hours per week in the northern population ( p = 0.042).

Conclusion:

Our data indicated that treatment strategy and adjusted work conditions have impact on work ability in MS.

Effectiveness of rehabilitation in multiple sclerosis relapse on fatigue, self-efficacy and physical activity

Relapse of disease is one of the most prominent characteristics of multiple sclerosis. Effectiveness of rehabilitation programmes on fatigue, self-efficacy (SE) and physical activity (PA) has not been investigated so far in context of relapse. The aim of our study was to examine if rehabilitation programme in addition to high-dose methylprednisolone (HDMP) during relapse of disease can influence fatigue, SE and PA more than corticosteroid therapy alone. Patients were randomized in control group receiving only HDMP and experimental group which was in addition included in rehabilitation programme. Outcome measures used were Fatigue Severity Scale (FSS), Multiple Sclerosis Self- Efficacy scale (MSSES), Godin Leisure-Time Exercise Questionnaire (GLTEQ), completed on baseline, 1 and 3 months later. There was no significant change in FSS in both time points, despite different trend seen between groups. The mean MSSES for function and control improved significantly in treatment group after 1 month (807.1 ± 96.8, p = 0.005; 665.3 ± 145.1, p = 0.05) and 3 months (820 ± 83.5, p = 0.004; 720.0 ± 198.2, p = 0.016.) compared to baseline values. The mean GLTEQ score was significantly higher in the treatment group compared to the control at both follow-up time points (45.7 ± 7.6, p < 0.001; 34.3 ± 22.4, p < 0.01). Rehabilitation started along with corticosteroid treatment induced significant improvement in PA compared to HDMP therapy alone. It also influenced noticeable changes in self-efficacy, but effect on fatigue was insufficient.

Sick leave and professional assistance for multiple sclerosis individuals in Vä sterbotten C ounty, northern Sweden

The aims of this study of a cross-sectional multiple sclerosis (MS) population in V ä sterbotten C ounty, northern Sweden, were to estimate the prevalence of sick leave, professional assistance and housing; to study risk factors for sick leave; and to estimate the odds for sick leave in comparison with the general population of the county. The consequences of MS-related incapacity on the socioeconomic factors studied were considerable. A lmost half (45%) of prevalent MS cases aged 18-64 years were fully sick listed and only one-third (35%) were not sick listed at all. Every fourth individual in the prevalence population received professional assistance, and 9% were living in care homes or special apartments for the disabled. Multiple logistic regression analysis identified the Expanded Disability Status Scale (EDSS) as the strongest predicto r of sick leave. The time from symptom onset to full sick leave leading to temporary or permanent disability pension was significantly shorter for cases with progressive onset, higher age at onset and in males. The risk of full sick leave due to MS was six times higher than in the general population.

Factors Associated with Employment Status in Individuals with Multiple Sclerosis

BACKGROUND

Unemployment is common in individuals with multiple sclerosis (MS) and is associated with substantial socioeconomic burden. Several MS-related factors have been found to be associated with employment status, including fatigue, depression, cognitive problems, and motor difficulties. However, few studies have examined these factors collectively in predicting employment. The present study aimed to explore these variables together in predicting employment status in MS.

METHODS

Fifty-three individuals with MS participating in a research study of cognitive, emotional, and social factors related to MS were examined. Composite scores were created using factor analysis that represented cognition, fatigue, depression, and motor function. These composite scores, along with the Expanded Disability Status Scale score, were explored as predictors of employment status (working, not working) via logistic regression. Models of mediation were also investigated.

RESULTS

A model including composite scores of motor function, cognition, depression, and fatigue significantly distinguished those who are unemployed versus employed. However, only the cognitive, motor, and fatigue composite scores were found to be significantly associated with unemployment individually. RESULTS of a mediation analysis using 1000 bootstrap samples indicated that the cognitive and fatigue composite scores significantly mediated the effect of disability on work status.

CONCLUSIONS

Cognitive function and fatigue mediate the effect of MS disability on employment status. Interventions targeting cognitive difficulties and fatigue in MS may be effective in helping individuals maintain employment.

[Difficulties experienced at work by patients with multiple sclerosis]

AIM

Multiple sclerosis (MS) is a disease of the central nervous system that affects young adults at a time when they launch into the workforce. The disease often has a great impact on working life. The objective of this survey was to identify the problems faced by people with multiple sclerosis in the context of their work.

METHODS

To describe the difficulties experienced at work by patients with multiple sclerosis, we carried out in 2010 a regional survey including neurology and functional rehabilitation centers.

RESULTS

Two hundred and seven MS patients of working age responded to the survey. The employment rate was 67.6%. Among difficulties expressed by patients, physical and mental fatigue appeared as the issues affecting work. For 41% of respondents, preventive measures at work could help maintain or resume employment.

CONCLUSION

Problems of fatigability put forward by MS patients are elements that can predict a loss of employment.

Employment among patients with multiple sclerosis-a population study

Objective

To investigate demographic and clinical factors associated with employment in MS.

Methods

The study included 213 (89.9%) of all MS patients in Sogn and Fjordane County, Western Norway at December 31^st 2010. The patients underwent clinical evaluation, structured interviews and completed self-reported questionnaires. Demographic and clinical factors were compared between patients being employed versus patients being unemployed and according to disease course of MS. Logistic regression analysis was used to identify factors independently associated with current employment.

Results

After a mean disease duration of almost 19 years, 45% of the population was currently full-time or part- time employed. Patients with relapsing –remitting MS (RRMS) had higher employment rate than patients with secondary (SPMS) and primary progressive (PPMS). Higher educated MS patients with lower age at onset, shorter disease duration, less severe disability and less fatigue were most likely to be employed.

Conclusions

Nearly half of all MS patients were still employed after almost two decades of having MS. Lower age at onset, shorter disease duration, higher education, less fatigue and less disability were independently associated with current employment. These key clinical and demographic factors are important to understand the reasons to work ability in MS. The findings highlight the need for environmental adjustments at the workplace to accommodate individual ’s needs in order to improve working ability among MS patients.

Demographic and clinical factors associated with changes in employment in multiple sclerosis

OBJECTIVE

The objective of this paper is to investigate demographic and disease factors associated with changes in employment role and status in multiple sclerosis (MS).

METHODS

Questionnaires on current symptoms, employment status and factors associated with changes in employment were sent to a community sample of 566 MS patients.

RESULTS

A total of 221 completed questionnaires were analysed. Of 169 employed at diagnosis, 43.3% had left employment at a mean of 11.9 years after disease onset. Of those still employed, 55% had changed their role or working hours to accommodate symptoms relating to their disease. These patients reported greater fatigue (p = 0.001), pain (p = 0.033) and memory problems (p = 0.038) than those whose employment had remained unaffected. Multinomial logistic regression revealed the factors most strongly predictive of employment status were disability level, years of education, disease duration and fatigue (p = 0.032).

CONCLUSIONS

Despite changes to public perceptions and legislative protection over the last 20 years, high rates of MS patients still leave the workforce prematurely, reduce working hours or change employment roles. These data have significant implications when considering social and economic impacts of MS, support the value of employment metrics as long-term outcome measures, and demonstrate the need to improve employment requirements and flexibility of working practices in individuals with MS.

Employment status in multiple sclerosis: impact of disease-specific and non-disease-specific factors

Background:

Multiple sclerosis (MS) is associated with high rates of early retirement (ER).

Objectives:

A German cohort of MS patients and healthy control subjects (HCs) were compared cross-sectionally to investigate disease- and non-disease-specific factors that are associated with employment status (ES) in MS and to identify predictors of ES in MS.

Methods:

A total of 39 ER MS patients, 48 employed MS patients, and 37 HCs completed a brief neuropsychological battery and questionnaires related to depressive symptoms, fatigue, health-related quality of life (HrQoL) and health locus of control (HLC). Neurological disability was assessed by the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC).

Results:

ER compared with employed MS patients scored significantly higher in neurological disability, depressive symptoms and fatigue and significantly lower in cognitive functioning and HrQoL. Further, both groups differed with regard to age, education, disease course and duration but not in HLC. Neurological disability, age and fatigue were identified as significant predictors of ES in MS.

Conclusions:

ES in MS was associated with demographic aspects, neurological and cognitive status, depressive symptoms, fatigue and HrQoL but was not associated with HLC. Findings confirm neurological disability, age and fatigue as independent predictors of ES in MS.

State vocational rehabilitation services and employment in multiple sclerosis

Background:

Obtaining and maintaining suitable employment can be a significant challenge for people with multiple sclerosis (MS).

Objective:

The objective of this article is to identify what vocational rehabilitation (VR) services helped MS clients obtain and maintain employment, after controlling for the effect of demographic covariates and disability-related government benefits.

Methods:

We retrieved data from the Rehabilitation Services Administration (RSA) 911 database in the fiscal year (FY) 2009, and used VR services as predictors to predict employment outcomes of people with MS by hierarchical logistic regression.

Results:

A total of 924 out of 1920 MS clients (48.1%) were successfully employed after receiving VR services. Logistic regression analysis results indicated that cash benefits (OR =0.51, p < 0.001) and public medical benefits (OR =0.76, p < 0.01) were negatively associated with employment outcomes, whereas counseling and guidance (OR = 1.68, p < 0.001), job placement assistance (OR = 2.43, p < 0.001), on-the-job supports (OR = 1.62, p < 0.01), maintenance services (OR = 1.59, p < 0.01), and assistive technology services (OR =2.09, p < 0.001) were significant predictors of positive employment outcomes.

Conclusion:

VR services were found to be associated with employment status. MS patients experiencing problems obtaining or maintaining employment should be encouraged to pursue services from state VR agencies.

Factors that influence the employment status of people with multiple sclerosis: a multi-national study

Paid employment is valuable for society and for the individual. A diagnosis of a chronic illness such as multiple sclerosis (MS) can influence a person's employment status. Previous studies have reported that demographic and disease-related aspects can predict whether a person with MS will leave their job. The aim of the study was to assess the factors that people with MS believe to contribute to their employment status and to determine whether any of these differentiate people with MS who are employed from those who are not employed. A multinational questionnaire assessed aspects related to employment that facilitate or hinder job maintenance. Data was collected in 18 European countries. A total of 1,141 questionnaires were completed. Of those responding, 694 (61%) subjects were employed and 477 (39%) were unemployed. The items that significantly differentiated the groups were related to MS symptoms, workplace environment and financial considerations. While MS influences employment status for many people who face difficult symptoms, aspects like a flexible work schedule and financial security are important and perhaps key to promoting job maintenance among people with MS.

The Multiple Sclerosis Work Difficulties Questionnaire

Background: A better understanding of the workplace difficulties experienced by people with multiple sclerosis (PwMS) may be critical to developing appropriate vocational and rehabilitative programs.

Objective: We aimed to assess the factor structure, internal consistency and validity of the new Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ).

Methods: Work difficulty items were developed and reviewed by a panel of experts. Using the MSWDQ, cross-sectional self-report data of work difficulties were obtained in addition to employment status and MS disease information, in a community-based sample of 189 PwMS.

Results: Exploratory Maximum Likelihood Factor Analysis on the draft questionnaire yielded 50 items measuring 12 factors. Subscale internal consistencies ranged from 0.74 to 0.92, indicating adequate to excellent internal consistency reliability. The MSWDQ explained 40% of the variance in reduced work hours since diagnosis, 40% of the variance in expectations about withdrawing from work, 34% of the variance in expectations about reducing work hours, and 39% of the variance in expectations about changing type of work due to MS.

Conclusion: The MSWDQ is a valid and internally reliable measure of workplace difficulties in PwMS. Physical difficulties, as well as cognitive and psychological difficulties were important predictors of workplace outcomes and expectations about future employment.

Screening for the risk of job loss in multiple sclerosis (MS): development of an MS-specific Work Instability Scale (MS-WIS)

Background: Multiple Sclerosis (MS) mainly presents amongst those of working age. Depending upon the type of MS, many people embark upon a long period of managing their day-to-day work-related needs in the face of intermittent and sometimes persistent disabling symptoms. The objective of this study was to explore the concept of work instability (WI) following the onset of MS and develop a Work Instability Scale (WIS) specific to this population.

Method: WI amongst those with MS in work was explored through qualitative interviews which were then used to generate items for a WIS. Rasch analysis was used to refine the scaling properties of the MS-WIS, which was then validated against expert vocational assessment by occupational health physiotherapists and ergonomists.

Results: The resulting measure is a 22-item, self-administered scale which can be scored in three bands indicating low, medium and high risk of WI (job retention) problems. The scale meets modern psychometric requirements for measurement, indicated by adequate fit to the Rasch model with absence of local dependency and differential item functioning (DIF) by age, gender and hours worked.

Conclusions: The scale presents an opportunity in routine clinical practice to take positive action to reduce sickness absence and prevent job loss.

Social consequences of multiple sclerosis: clinical and demographic predictors - a historical prospective cohort study

BACKGROUND

Time to disability pension is one of the endpoints to be used to determine the prognosis of multiple sclerosis (MS) in prospective studies.

OBJECTIVE

  To assess the time to cessation of work and receiving disability pension in MS, and how it may depend on gender, type of work and age and symptom at onset.

METHOD

A total of 2240 Danes with onset of definite/probable MS 1980-1989, identified from the Danish MS-Registry, were included. Information on social endpoints was retrieved from Statistics Denmark. Cox regression analyses were used with onset as starting point.

RESULTS

Afferent onset symptoms [hazard ratio (HR 0.57)] and non-physical type of work (HR 0.70) were favourable prognostic factors compared with high age at onset, physical work and efferent symptoms at onset. The mean time to disability pension was 13 years for patients with afferent/brainstem onset symptom but 8.7 years for those with efferent onset symptoms (P < 0.0001). The effect of onset symptom was reduced and the effect of sex became significant when all covariates and age at onset were included in multivariate Cox regression.

CONCLUSIONS

Onset age, type of onset symptom and work are robust predictors of disability pension in MS. Disability pension proves to be a reliable milestone in estimation of the prognosis of MS.

A health-economic evaluation of disease-modifying drugs for the treatment of relapsing-remitting multiple sclerosis from the German societal perspective

OBJECTIVE

This analysis compared the cost-effectiveness of interferon beta-1a (IFNbeta-1a) 44 microg SC with that of other available first-line treatments for relapsing-remitting multiple sclerosis (RRMS) from the German societal perspective in 2008.

METHODS

A decision-analytic model was used to estimate the cost-effectiveness of IFNbeta-1a 44 microg SC given 3 times weekly compared with that of IFNbeta-la 30 microg IM given once weekly, IFNbeta-1b 8 mIU given every other day, and glatiramer acetate 20 mg SC given once daily. Data sources included the published literature, clinical trials, German price/tariff lists, and national population statistics. The time horizon of the model was 4 years, which was the maximum duration of follow-up in published clinical trials.

RESULTS

The cost-effectiveness (cost per relapse avoided) of IFNbeta-la 44 microg SC compared with no active treatment was euro51,250, which compared favorably with that of IFNbeta-la 30 microg IM (euro133,770), glatiramer acetate (euro71,416), and IFNbeta-1b (euro54,475). When the cost of disease progression was excluded, the cost per relapse avoided remained favorable for IFNbeta-1a 44 microg SC (euro54,292) compared with the other options (euro143,186, euro72,809, and euro56,816, respectively). Indirect comparison of each available treatment option with the next best alternative indicated that the incremental cost-effectiveness of IFNbeta-la 44 microg SC (euro23,449) was consistent with accepted thresholds. Sensitivity analyses in which the discount rate, frequency of relapse and disease progression, costs of relapse and disease progression, and adherence were varied did not affect the relative outcomes.

CONCLUSION

In this analysis from the German societal perspective, IFNbeta-la 44 microg SC had favorable overall cost-effectiveness versus no active treatment compared with other available disease-modifying drugs for the treatment of RRMS.

Health and quality of life in patients with relapsing multiple sclerosis: making the intangible tangible

Multiple sclerosis is diagnosed primarily in young adults with aspirations for both family and careers. For this reason, it is important to take into account the potential impact of disease and treatment on these aspirations, which relate to quality of life. Quality of life evaluations and measurements have now become an integral part of comprehensive care for multiple sclerosis patients. Moreover, quality of life endpoints are now included in most therapeutic trials of potential new treatments, as well as in observational studies of the management of multiple sclerosis. The scope of quality of life includes self-perceived status in three important domains of life, namely physical (e.g. disability, strength), psychological (e.g. depression, fatigue) and social functioning (e.g. employment, usual daily activities). A number of studies have demonstrated a positive impact on quality of life of treatment with glatiramer acetate in the above areas. Several of these included direct comparisons between glatiramer acetate and interferon-beta. it is important that quality of life issues are addressed at the outset by patients and professionals, and taken into account when choosing the most appropriate therapy for a given individual.

Actual reality: a new approach to functional assessment in persons with multiple sclerosis

OBJECTIVE

To examine the use of an innovative approach for assessing everyday life activities of people with multiple sclerosis (MS): Actual Reality. Actual Reality is a performance-based assessment approach that involves the use of the internet to perform real, everyday life activities.

DESIGN

A between-subjects design.

SETTING

Outpatient rehabilitation institute.

PARTICIPANTS

Persons (n=21) with clinically definite MS and healthy controls (HCs) (n=18) without any reported neurologic disabilities participated in this study. Participants were between the ages of 21 to 60 years, and the sample consisted of volunteer sample.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants were asked to access the internet to purchase airline tickets for a round trip flight and were administered the Minimal Assessment of Cognitive Functioning in Multiple Sclerosis. Participants also completed questionnaires to assess quality of life (Functional Assessment of Multiple Sclerosis), functional status (Functional Behavior Profile), and prior Internet experience.

RESULTS

The MS group displayed significantly more difficulties than the HC group in accurately and independently completing the Actual Reality task primarily because of cognitive impairment. Self-report of quality of life and functional status were not correlated with Actual Reality performance in the group of people with MS. However, the self-report measures were significantly associated with affective symptomatology.

CONCLUSIONS

These results provide initial evidence supporting the use of the Actual Reality approach in assessing persons with MS performing everyday life activities. Actual Reality is a significant step forward in increasing the sensitivity, accessibility, and relevancy of functional assessments in people with cognitive and physical disabilities.

Social consequences of multiple sclerosis (1): early pension and temporary unemployment--a historical prospective cohort study

Multiple sclerosis affects young and middle-aged people and often leads to physical and cognitive handicaps. There is a need for detailed knowledge of the social consequences of the disease. We aim here to describe the course of the working life and career of multiple sclerosis patients at the time of onset and thereafter, in terms of probability of early pension and income development. All 2538 patients with multiple sclerosis in Denmark with disease onset between 1980 and 1989, identified through the Danish MS-Registry, were included in this study. Twenty matched control persons per patient were randomly drawn from the civil registration system. Information on economic status was retrieved from Statistics Denmark. A survival analysis technique was used with onset as the starting point. We found that the probability of remaining without early pension was at 5 years 70% for patients and 97% for controls, and at 20 years 22% for patients and 86% for controls. Due to lower rates for early pension, gross income with time was lower in patients than controls. We conclude that multiple sclerosis seriously affects the economic life of multiple sclerosis patients, even within a few years of onset.

[Quality of life assessment in patients with multiple sclerosis]

BACKGROUND/AIM

Multiple sclerosis (MS) is a chronic inflammatory disease of central nervous system. The main physiopatological feature of MS is demyelination. Multiple sclerosis is one of three most common causes of severe disability in youngest people. In patients with MS, apart from complete psychophysical status and objective neurologic status, a subjective perception of symptoms and signs, known as quality of life, must be considered, too. The aim of this study was to estimate a health related quality of life (HRQoL) in patients with multiple sclerosis (MS) and to investigate the correlations between scores of HRQoL and selected demographic and clinical parameters.

METHODS

A cross-sectional study was performed in patients meeting following inclusion criteria: MS diagnosis (McDonald's criteria), age 18-60 years, the Expanded Disability Status Scale (EDSS) < 8, and written informed consent. Exclusion criteria were exacerbation of MS in the last month, any preexisting major chronic illness and/or psychiatric disorders and antidepressive and/or corticosteroid therapy in the last month. The quality of life was measured by a disease specific instrument, MSQoL-54 (The Multiple Sclerosis Quality of Life). The neurological impairment was assessed using the Expended Disability Status Scale (EDSS) and Mini Mental Scale (MMS). The presence and severity of depression was estimated by the Hamilton Depression Rating Scale (HDRS). The presence and severity of fatigue was assessed by the Fatigue Severity Scale (FSS). Statistical analysis included descriptive statistics and correlation analysis.

RESULTS

The higher HRQoL score was registered for mental health (56.3 +/- 19.5) than for physical one (51.3 +/- 17.9), which means that physical disability had more important influence on quality of life deterioration comparing to mental health. The highest values of HRQoL were observed in domains of Cognitive Functioning (77.4 +/- 22.5) and Pain (75.7 +/- 25.5). The lowest scores of HRQoL were registered in domains of Role Limitations due to Physical Problems (32.5 +/- 42.0) and Role Limitations due to Emotional Problems (44.6 +/- 47.8). HRQoL scores statistically significantly correlated with natural history of MS, duration of diseases, employment and marriage status of participants. Deterioration in quality of life scores in the most of MSQoL-54 scales and subscales statistically significantly correlated with the presence and severity of physical disability, depression status and fatigue in patients with MS.

CONCLUSION

This study showed that different demographic and clinical parameters had a major influence on HRQoL impairment in the sample of patients with MS.

Cognitive impairment in multiple sclerosis

Multiple sclerosis (MS) is a progressive disease of the CNS that is characterised by widespread lesions in the brain and spinal cord. MS results in motor, cognitive, and neuropsychiatric symptoms, all of which can occur independently of one another. The common cognitive symptoms include deficits in complex attention, efficiency of information processing, executive functioning, processing speed, and long-term memory. These deficits detrimentally affect many aspects of daily life, such as the ability to run a household, participate fully in society, and maintain employment--factors that can all affect the overall quality of life of the patient. The increased use of neuroimaging techniques in patients with MS has advanced our understanding of structural and functional changes in the brain that are characteristic of this disease, although much remains to be learned. Moreover, examination of efforts to treat the cognitive deficits in MS is still in the early stages.

Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis

BACKGROUND

Multiple sclerosis is a neurological disease that frequently affects adults of working age, resulting in a range of physical, cognitive and psychosocial deficits that impact on workforce participation. Although, the literature supports vocational rehabilitation (VR) approaches in persons with multiple sclerosis (pwMS), the evidence for its effectiveness is yet to be established.

OBJECTIVES

To evaluate the effectiveness of VR programs compared to alternative programs or care as usual on return to work, workability and employment in pwMS; to evaluate the cost effectiveness of these programs.

SEARCH STRATEGY

Electronic searches included: Cochrane Central Register of Controlled Trials "CENTRAL" 2008 issue 3, MEDLINE (PubMed) (1966- 2008), EMBASE (1988- 2008), CINAHL (1982- 2008), PEDro (1990- 2008), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register.

SELECTION CRITERIA

Randomized and controlled clinical trials, including before - after controlled trials, that compare VR rehabilitation with alternative intervention such as standard or a lesser form of intervention or waitlist controls.

DATA COLLECTION AND ANALYSIS

Two reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis was performed, based on methodological quality. Trials were grouped in terms of type and setting of VR programs.

MAIN RESULTS

Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a)'competitive employment', in altering rates of job retention, changes in employment, improvement in rates of re-entry into the labour force; (b) for altering 'work ability' by improving participants' confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost-effectiveness.

AUTHORS' CONCLUSIONS

There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment. Proactive and timely VR programs should incorporate practical solutions to deal with work disability, workplace accommodation and educate employers, and the wider community. Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs. Future research in VR should focus on improving methodological and scientific rigour of clinical trials; on the development of appropriate and valid outcome measures; and on cost effectiveness of VR programs.

Employment in multiple sclerosis. Exiting and re-entering the work force

Multiple sclerosis (MS) is associated with significant economic burden and high rates of unemployment. This investigation evaluated patient and disease characteristics associated with work loss and work initiation using the NARCOMS patient registry. Patient and disease characteristics associated with transitions to unemployment or employment were evaluated cross-sectionally and prospectively over the course of two assessment periods (mean interval of 1.56 +/- 0.93 years). Eligible participants included 8,867 patients for the cross-sectional component, and 8,122 for longitudinal analyses. At Time 1 and Time 2 56-58 % of MS patients were not employed. At Time 1, unemployed participants more likely to have a progressive disease course, had a longer symptom duration, greater levels of disability as measured by the PDDS, and greater functional limitations across all domains of the performance scales (p < 0.0001 for all). At Time 2, increasing MS symptoms in the past 6 months increased the odds of becoming unemployed. In addition, specific problems in mobility, hand function, fatigue, and cognitive performance domains were associated with increased odds of becoming unemployed. Less severe problems in similar areas, including mobility, hand function, and cognitive functioning were also predictive of work initiation among patients not employed. MS is associated with high rates of unemployment. Specific physical and mental health limitations confer risk of employment cessation over time, as well as the likelihood of employment initiation. This study has implications for rehabilitation interventions to target specific MS related limitations that place patients at greatest risk for work status changes.

[Characteristics of patients suffering from multiple sclerosis according to professional situation]

AIM

To describe the health and professional status of multiple sclerosis patients of working age and to compare a group of patients in work (group T1) with a group of unemployed patients (group T2).

MATERIALS AND METHODS

A case-controlled study was performed. In the course of a specific consultation with a neurologist, demographic, medical and professional data were gathering using a questionnaire. Descriptive and comparative statistical analyses were then performed.

RESULTS

A total of 76 patients were included in the study: 54 were in work (group T1) and 22 were unemployed (group T2). Hence, the employment rate was 71%, with an average time since disease onset of nine years at the time of the study. Low educational level (p=0.02), disease progression (p=0.0001), the presence of motor symptoms (p=0.01), cerebellar symptoms (p=0.02) or cognitive symptoms (p=0.03), a worse EDSS (p=0.0001) and a job requiring force (p=0.05) or manual dexterity (p=0.05) were found to be negative factors. Employment in the public sector (p=0.003) or large companies (p=0.03) were found to be protective factors. Access to the workplace was better for currently employed patients (p=0.03).

CONCLUSION

This study shows that differences exist within the MS patient population according to the professional situation. It underlines the importance of clinical and demographics variables as determinants of differences in employment status. Not surprisingly, unemployed patients are more likely to have been classified as handicapped workers. Factors linked to work-induced constraints did not emerge from the survey because the questionnaire items were not appropriate for addressing this latter issue.

Vocational rehabilitation services for people with multiple sclerosis: what patients want from clinicians and employers

BACKGROUND

The NSF for Long-term Neurological Conditions highlights the need for vocational rehabilitation services. Although the barriers to work for people with MS (pwMS) have been clearly identified, there has been little research that identifies the type of support required.

OBJECTIVE

To identify what pwMS require from a vocational rehabilitation service in terms of content and service delivery.

DESIGN OF STUDY

Four focus groups of pwMS, currently in employment, were convened. These were audio-taped and content analysed using a constant comparison method.

RESULTS

People with MS identified two key needs; managing performance and managing expectations. Performance difficulties could be managed either by treating symptoms, by changing the environment, or by altering the demands of the job. PwMS highlighted the need for counselling to help them, and advocacy to help their employers have appropriate expectations.

CONCLUSION

PwMS need support in the workplace in two distinct ways. First, by managing the interaction between the impairments caused by MS, the physical environment, and the demands imposed by the work. Second, by providing expert knowledge about the employment environment and the needs of employers, an awareness of the relevant legislation and counselling in supporting people to adapt, adjust and resolve complex issues.

Effects of education level and employment status on HRQoL in early relapsing-remitting multiple sclerosis

Purpose To evaluate the effects of education level and employment status on health-related quality of life (HRQoL) in a large cohort of patients affected by relapsing-remitting multiple sclerosis (RRMS). Patients This study included 648 patients with RRMS attending 40 Italian MS centers. Inclusion criteria were an Expanded Disability Status Scale (EDSS) score between 1.0 and 5.5; stable disease on enrollment; and no previous treatment with interferons, glatiramer acetate, or immunosuppressive drugs. Quality of life (QoL) was evaluated by the Multiple Sclerosis Quality of Life-54 questionnaire (MSQoL-54).

Results Employed patients scored significantly higher than other patient groups in the majority of MSQoL-54 domains. Similarly, patients with academic degrees and secondary education had higher scores than those with primary education (ie, eight years of education) in several domains of HRQoL. Patients who were employed with a high educational level achieved significantly better scores than unemployed patients with a lower educational level. In multivariate analysis, occupation and educational level were found to be significant and independent predictors of HRQoL.

Conclusions The results of our study suggest the importance of sustaining employment after a recent diagnosis of MS. In addition, education has a great influence on HRQoL; a higher education level may determine a stronger awareness of the disease, and a better ability to cope with the challenges of a chronic disease such as MS. Multiple Sclerosis 2007; 13: 783-791. http://msj.sagepub.com

Multiple sclerosis: disability profile and quality of life in an Australian community cohort

The objective of this study was to determine the experience of disability and reported symptoms in multiple sclerosis in an Australian community sample, comparing the perceptions of patients, carers and treating doctors, and to examine effects on quality of life, carer stress and utilization of health services. The study design used a prospective cross sectional community survey. The participants were persons with a confirmed diagnosis of multiple sclerosis, with quantified neurological, mobility and cognitive deficits, from a tertiary hospital database (n=101), who lived at home, and their carers and doctors. The study method used demographic, diagnostic and disease severity data extracted from the database. Structured interviews conducted at home included: (1) open questionnaires for participant, carer and general practitioner, prioritizing symptoms/problems affecting daily living; and (2) standardized assessments for patient quality of life, caregiver strain and perceived burden of care. The mean age was 49 years (range 28-64). Those more severely affected had a significantly reduced quality of life and increased carer burden than those with milder disability, but discordance between patients, carers and doctors was noted in their perception of problems and symptom experience. Rates of depression (67%) and work-related problems were high, but vocational support was rarely provided. Forty persons used interferon, of whom 20 had secondary progressive multiple sclerosis; 39% reported difficulty in accessing rehabilitation services and only 10% were referred to medical rehabilitation units. In conclusion, the rates of disability and symptom experience were similar to other series; however, access and utilization of appropriate rehabilitation and support services appears to be lacking. There were higher reported rates of depression and poor quality of life. Opportunities may possibly exist to re-deploy resources to develop vocational support, counselling and rehabilitation.

Neuropsychology of multiple sclerosis--an overview

Neuropsychological dysfunctions have been well documented in patients with multiple sclerosis. We herein give an overview of the main findings of recent decades. The pros and cons of considering the cognitive deficits of multiple sclerosis patients as a form of 'subcortical dementia' are discussed. By comparing the neuropsychological descriptions of multiple sclerosis patients as given in the literature to other neurological diseases which are also associated with neuropsychological deficiencies, we propose the term 'multiple disconnection syndrome' to describe the variety of neuropsychological deficits encountered in this demyelinating disease. Furthermore, a ' threshold of cerebral tolerance' is assumed which must be crossed before cognitive dysfunctions are manifested clinically.

A longitudinal survey of self-assessed health trends in a community cohort of people with multiple sclerosis and their significant others

BACKGROUND

Studies assessing psychosocial consequences of multiple sclerosis (MS) in the community are scarce; it appears that there are no longitudinal surveys in this area.

OBJECTIVES

We prospectively assessed changes in self-perceived health status over 5 years in a community cohort of MS adults.

METHODS

The 251 people who participated in a 1999 postal survey were re-assessed in 2004, being sent the Multiple Sclerosis Quality-of-Life-54 (MSQOL-54), the Chicago Multiscale Depression Inventory (CMDI), and a demographic/clinical questionnaire. Health-related quality of life (Short Form-36) and CMDI were also assessed in participants' significant others.

RESULTS

A total of 205 people participated: 14 (5.6%) of the original cohort MS had died and 32 (13%) did not return the questionnaires. A significant other was available for 74% of responders. The proportion requiring constant bilateral walking assistance increased from 16% to 33%. The proportion using housing adaptations increased from 17% to 27%, and the use of daily home care increased from 19% to 28%. Impaired CMDI mood affected 27% of MS and 19% of significant others. Changes in MSQOL-54 were not unidirectional: the domains change in health, physical function, and general health worsened; while social function, mental health, and health distress improved significantly.

CONCLUSIONS

MS has a pervasive but inhomogeneous impact on the lives of MS sufferers: the proportion of those severely impaired doubled over the study period; nevertheless in 23% of participants the disease remained mild over a median duration of 11 years. The psychological burden affects not only people with MS but also their significant others.

Treating learning impairments improves memory performance in multiple sclerosis: a randomized clinical trial

This randomized clinical trial utilized established techniques to improve new learning and memory performance in multiple sclerosis (MS) participants with learning impairment. Participants were 29 individuals with clinically definite MS with documented learning deficits, randomly assigned to the experimental or control group. The experimental group underwent eight sessions of the Story Memory Technique (SMT), while the control group participated in eight sessions of memory exercises. Neuropsychological assessment was conducted at baseline, immediately following treatment and 5 weeks later to assess outcome. When stratifying participants by degree of learning deficits, a significant treatment effect was noted. MS participants with moderate-severe impairment in learning showed a significant improvement in learning abilities when compared to controls, (t(19) =3.32, P<0.01) evident in 88% of participants in the experimental group. Little improvement was noted in MS participants with mild learning impairments. Significant self-reported improvements in memory were noted in MS participants that underwent treatment, but not those that did not undergo treatment (t(26) =2.55, P<0.01). Results indicate that learning and memory deficits in MS can be effectively treated through a memory rehabilitation program utilizing context and imagery to improve new learning. Appropriate patient selection is important, with moderately-severely impaired individuals showing significantly greater benefit from treatment.

Role of health-related quality of life measures in the routine care of people with multiple sclerosis

Health-related quality of life instruments are expected to be of particular value in routine care of people with multiple sclerosis (MS), where they may facilitate the detection of disease aspects that would otherwise go unrecognised, help clinicians appreciate patient priorities particularly in terms of treatment goals, facilitate physician-patient communication, and promote shared decision-making. However, it appears that these instruments are little used routine clinical approaches to people with MS. To address this issue, I performed a bibliographic search of studies that evaluated the efficacy of generic or disease-specific health-related quality of life (HRQOL) instruments in MS clinical practice from clinicians' or patients' perspectives. I found only one cross-sectional study, which compared preferences for three instruments, and assessed acceptability in people with MS. Reasons for lack of transfer of HRQOL measurements to clinical practice may be cultural, methodological, or practical. With regard to MS, the proliferation of instruments seems to constitute a barrier, with no particular instrument having gained wide popularity or consensus. Other barriers are lack of resources for the administration, collection and storage of the data, and inability of clinicians to score, interpret, and use HRQOL instrument to guide clinical care. It is therefore important to refine existing tools, extending clinical validation to wider contexts and cultures. More studies assessing acceptability and clinicians' and patients' preferences for different instruments are also required.

Measures of physical and cognitive function and work status among individuals with multiple sclerosis: a review of the literature

The purpose of this review was to critically evaluate the multiple sclerosis (MS) literature that has examined physical and cognitive function in relation to ability to work. Although numerous factors may be considered when determining work ability, physical and/or cognitive functional limitations associated with MS are presumably the primary determinants of work capacity. An exhaustive search of the literature produced 20 research articles that described 18 studies. Findings from these studies support that limitations in physical or cognitive function can hinder one's ability to work; however, ability to work could not be based solely on these measures of function. Work ability among individuals extended beyond measures of impairment to include level of education, job characteristics, and disease symptoms such as fatigue. In summary, measures of physical and cognitive function can guide physicians when clinically evaluating an individual with MS, but are poor indicators for precluding an individual from working.

L’évaluation médico-économique dans la sclérose en plaques

In multiple sclerosis, evaluation of quality of life is important because the patients are usually confronted with a decrease in physical, cognitive and social functioning. Apart from the personal suffering, the financial consequences for these patients and their family and the economic burden for society are enormous. Measurement of health related quality of life is important for the understanding of disease burden and the impact of specific MS treatments. Rising costs associated with new treatments and spending limits have prompted a search for gratter efficiency. Although health economics research can suggest ways to maximize health benefits within fixed budgets it is currently underused in MS. The purpose of this review of the literature is to explain some of the basic principles underlying both quality of life and economic evaluations, and analyse their contribution to understanding and managing patients with MS. Neurologists should not underestimate how dramatic their contributions can be to this maturing field that will influence the future of MS patients care.

Cognitive impairment in patients suffering from relapsing-remitting multiple sclerosis with EDSS < or = 3.5

OBJECTIVES

Previous papers have mainly demonstrated the presence and the frequency of cognitive impairment in patients suffering from relapsing-remitting multiple sclerosis. The purpose of this study was to investigate subjects with the relapsing-remitting form of the disease and mild clinical disability (EDSS < or = 3.5), so as to quantify this deficit when the illness does not yet interfere with daily living and the ability to work.

METHODS

Fifty patients and 50 healthy controls were submitted to a wide neuropsychological battery, including Wechsler Memory Scale I- (WMS), Benton Visual Retention Test D- (BVRT), Raven Coloured Progressive Matrices (RCPM), Kohs' test (KT), Judgement of Lines Orientation H- (JLO), Facial Recognition (FR) and Aachner Aphasie Test (AAT). They also underwent Clinical Depression Scale (CDQ) and State-Trait Anxiety Inventory (STAI).

RESULTS

The results show the presence of significant memory impairment on both WMS (P = 0.000) and BVRT (P = 0.000) in patients compared with controls. Patients were also impaired in abstract reasoning and problem-solving deficit (KT P = 0.003; RCPM P = 0.000) and in FR (P = 0.019). Cognitive decline correlated with illness duration (r = 0.761), but was independent of EDSS (r = 0.085).

CONCLUSION

Cognitive decline was present even when physical disability was not yet severe, but it was mild and did not limit patients' ability to work. The cognitive impairment outlined was of the subcortical type and correlated with illness duration. This study emphasizes the importance of cognitive examination in clinical practice. It is suggested that a complete neurological examination include tests on memory and abstract reasoning.

Multiple sclerosis

Multiple sclerosis (MS) is the most common disabling neurologic disease of young people affecting between 350 and 450,000 individuals in the United States. Substantial advances have been made in the diagnostic assessment and treatment interventions over the last 10 years such that we are now able effectively to treat both the disease process and the associated symptomatic complaints associated with MS. Most patients consult with their primary care physician at the time when the first clinical manifestations of MS emerge. These physicians play a central role in the early identification and treatment of patients with MS. This article emphasizes the expanding diagnostic and therapeutic capabilities evolving for the MS patient and the crucial role played by primary care physicians in collaboration with neurologists in the coordination of the initial diagnostic and treatment plan.

Short term predictors of unemployment in multiple sclerosis patients

BACKGROUND

Unemployment is common in people with multiple sclerosis (MS) and is associated with loss of income and impaired health related quality of life. This study determined variables associated with unemployment and risk factors for the development of unemployment in people with MS.

METHODS

Ninety-six patients who were under age 65 and participated in two previous studies to measure economic costs and health related quality of life in MS were included. The baseline employment rate and variables associated with unemployment at baseline were determined. The ability of these variables to predict unemployment over the next two and a half years was then evaluated.

RESULTS

At baseline 50.1% (50/96) of participants were employed. Two and a half years later only 40.6% (39/96) remained employed. This represents loss of employment for 22.0% (11/50) of those originally employed. Factors associated with unemployment at baseline included greater disability, progressive disease course, longer disease duration, and older age. Risk factors for loss of employment over the next 2.5 years included greater disability and older age.

CONCLUSIONS

This study confirms the low employment rate among people with MS and confirms the association of several previously-reported factors with greater risk of unemployment. It is also the first study to confirm that some of these factors also increase the risk of future unemployment. People with MS who are over age 39 or have moderate disability and are still employed can now be identified as at risk for becoming unemployed over the next 2.5 years. They should be considered for interventions to maintain employment or to lessen the impact of unemployment.

Cost-effectiveness analysis of interferon beta in multiple sclerosis: a Markov process analysis

OBJECTIVE

The objective of this study was to examine the cost-effectiveness of preventive treatment with interferon beta (IFNB) versus no preventive treatment in patients with multiple sclerosis.

METHODS

The setting for this study was the United Kingdom. A lifetime Markov process model was constructed to model the average quality-adjusted life years (QALYs) and the costs of both treatment strategies. Data for the construction of the model came from published literature, including large multicenter randomized clinical trials in relapsing-remitting and secondary progressive multiple sclerosis. Costs were obtained from published sources.

RESULTS

The results of the baseline analysis from the National Health Service (NHS) perspective showed that the use of interferon beta as preventive treatment for MS increased the total average discounted cost from 51,214 Pounds to 221,436 Pounds per patient. The undiscounted effectiveness increased from 24.9 QALYs to 28.2 QALYs, resulting in an incremental cost-effectiveness ratio of 51,582 Pounds per QALY. Sensitivity analyses showed the robustness of this model for other interferons.

CONCLUSION

The study showed that preventive treatment with interferon beta in patients with multiple sclerosis may not be fully justified from a health-economic perspective, although interferon beta is associated with an improved effectiveness compared with no preventive treatment.

Disability and prognosis in multiple sclerosis: demographic and clinical variables important for the ability to walk and awarding of disability pension

OBJECTIVE

To evaluate disability and prognosis in an untreated population-based incidence cohort of multiple sclerosis (MS) patients.

METHODS

The Expanded Disability Status Scale (EDSS) score was recorded in 220 MS patients. Disease progression was assessed by life table analysis with different endpoints and multivariate Cox regression analysis was performed for evaluation of prognostic factors.

RESULTS

The probability of being alive after 15 years was 94.8 +/- 1.8% (s.e.), of managing without a wheelchair (EDSS < 7.0) 75.8 +/- 3.2%, of walking without walking assistance (EDSS<6.0) 60.3 +/- 3.6%, and of not being awarded a disability pension 46.0 +/- 3.7%. The probability of still having a relapsing-remitting (RR) course after 15 years was 62.0 +/- 4.1%. A RR course and long interval between the initial (onset) and second episode (> 3 years) predicted favorable outcome. There was also a trend towards favorable outcome in patients with optic neuritis, sensory symptoms and low age at onset but these factors were associated with the RR course. Motor symptoms and high age at onset indicated unfavorable outcome, but these factors were associated with the primary progressive course.

CONCLUSIONS

A RR course and long inter-episode intervals in the early phase of the disease were associated with a better outcome. Other onset characteristics indicating a favorable outcome were associated with the RR course while characteristics indicating an unfavorable outcome were associated with the PP course.