Use of healthcare services by patients with multiple sclerosis in France over 2010-2015: a nationwide population-based study using health administrative data

Primary healthcare needs and service utilisation of people with disability: a data linkage protocol

INTRODUCTION

General practitioners (GPs) play a crucial role in the early management and treatment of the comorbidities and complications experienced by people with disability. However, GPs experience multiple constraints, including limited time and disability-related expertise. Knowledge gaps around the health needs of people with disability as well as the frequency and extent of their engagement with GPs mean evidence to inform practice is limited. Using a linked dataset, this project aims to enhance the knowledge of the GP workforce by describing the health needs of people with disability.

METHODS AND ANALYSIS

This project is a retrospective cohort study using general practice health records from the eastern Melbourne region in Victoria, Australia. The research uses Eastern Melbourne Primary Health Network (EMPHN)-owned de-identified primary care data from Outcome Health's POpulation Level Analysis and Reporting Tool (POLAR). The EMPHN POLAR GP health records have been linked with National Disability Insurance Scheme (NDIS) data. Data analysis will involve comparisons across disability groups and the rest of the population to explore utilisation (eg, frequency of visits), clinical and preventative care (eg, cancer screening, blood pressure readings) and health needs (eg, health conditions, medications). Initial analyses will focus on NDIS participants as a whole and NDIS participants whose condition is either an acquired brain injury, stroke, spinal cord injury, multiple sclerosis or cerebral palsy, as classified by the NDIS.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Eastern Health Human Research Ethics Committee (E20/001/58261), and approval for the general collection, storage and transfer of data was from the Royal Australian College of General Practitioners National Research Ethics and Evaluation Committee (protocol ID: 17-088). Dissemination mechanisms will include the engagement of stakeholders through reference groups and steering committees, as well as the production of research translation resources in parallel with peer-reviewed publications and conference presentations.

Pregnancy-related healthcare utilization among women with multiple sclerosis

Introduction

Many studies have investigated pregnancy in women with multiple sclerosis (MS). However, no study has measured prenatal healthcare utilization in women with MS or adherence to follow-up recommendations to improve antenatal care quality. A better knowledge of the quality of antenatal care in women with MS would help identify and better support women with insufficient follow-up. Our objective was to measure the level of compliance to prenatal care recommendations in women with MS using data from the French National Health Insurance Database.

Methods

This retrospective cohort study included all pregnant women with MS who gave live birth in France between 2010 and 2015. Using the French National Health Insurance Database, follow-up visits with gynecologists, midwives, and general practitioners (GPs) were identified, as well as ultrasound exams and laboratory tests. Based on the Adequacy of Prenatal Care Use and Content and Timing of care in Pregnancy indices, a new tool adapted to the French recommendations was developed to measure and classify the antenatal care trajectory (adequate or inadequate). Explicative factors were identified using multivariate logistic regression models. A random effect was included because women may have had more than one pregnancy during the study period.

Results

In total, 4,804 women with MS (N = 5,448 pregnancies ending in live births) were included. When considering only visits with gynecologists/midwives, 2,277 pregnancies (41.8%) were considered adequate. When adding visits with GP, their number increased to 3,646 (66.9%). Multivariate models showed that multiple pregnancy and higher medical density were associated with better adherence to follow-up recommendations. Conversely, adherence was lower in 25-29-year-old and >40-year-old women, in women with very low income, and agricultural and self-employed workers. No visits, ultrasound exams, and laboratory tests were recorded in 87 pregnancies (1.6%). In 50% of pregnancies, women had at least one visit with a neurologist during the pregnancy, and women restarted disease-modifying therapy (DMT) within 6 months after delivery in 45.9% of pregnancies.

Discussion

Many women consulted their GP during pregnancy. This could be linked to a low density of gynecologists but may also reflect the preferences of women. Our findings can help adapt recommendations and healthcare providers' practices according to the women's profiles.

Assessing the Risk of Relapse Requiring Corticosteroids After In Vitro Fertilization in Women With Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Several studies have shown an increased risk of relapse after in vitro fertilization (IVF) in women with multiple sclerosis (MS), especially when a gonadotrophin-releasing hormone (GnRH) agonist stimulation protocol was used. Our objective was to investigate the risk of relapse after IVF in women with MS, overall and according to stimulation protocol (GnRH agonists vs antagonists), using data from the French national health insurance database.

METHODS

This retrospective cohort study included all women with MS who have benefited from IVF between January 1, 2010, and December 31, 2015, in France. Three-month exposed periods after IVF were compared with unexposed periods before IVF, each woman being her own control. Four outcomes were considered: annualized relapse rate (ARR), proportion of IVF with relapse, difference in the number of relapses "after-before," and the delay from IVF to the first relapse. Relapses were identified by an algorithm based on MS-related hospital admissions and the use of corticosteroid therapy. Stimulation protocols and disease-modifying therapies (DMTs) were identified using drug claims. Zero-inflated Poisson regression models adjusted for age at IVF and the presence of DMT were used. A random effect on women was included because women may undergo multiple IVF procedures. Subgroup analyses by stimulation protocol and IVF outcome (pregnancy or failure) were conducted.

RESULTS

A total of 225 women accounting for 338 IVF procedures were included (the mean age at the first IVF 34.6 ± 4.5 years; 36% of women underwent at least 2 IVF procedures during the period). No increase in the risk of relapse after IVF was found overall (before vs after IVF: 0.20 vs 0.18 relapse per patient-year; 7.7% vs 7.1% of IVF with women having at least one relapse) and in subgroups. A lower ARR before and after IVF was observed among women who remained treated until IVF.

DISCUSSION

The maintenance of DMT until IVF seemed to be a determining factor in reducing the risk of relapse. Women with MS should be reassured because we did not show an increased risk of relapse requiring the use of corticosteroid therapy after IVF neither with GnRH agonists nor with GnRH antagonists.

Trends in disease-modifying therapy use in patients with multiple sclerosis using a 10-year population-based cohort study in France

BACKGROUND

The availability of new disease-modifying therapies (DMTs) for patients with multiple sclerosis (MS) provides an opportunity for improving outcomes but makes disease management more complex. Our study aimed to describe changes in therapeutic practices over the period 2009-2018 and measure the impact of the arrival of oral DMTs on the use of injectable DMTs.

METHODS

Data were extracted from a representative 1/97 sample of the French population covered by the healthcare insurance system. Study period was set from 1 January 2009 to 31 December 2018. Four periods of MS identification were defined (before 2009, 2009-2011, 2012-2015 and 2016-2018).

RESULTS

Overall, 1,508 patients with MS were included, of whom 876 (58.1%) were treated at least once over the study period. Untreated patients were older and had more comorbidities than treated ones. First-line DMTs were the most frequent initial DMT (78.5%) and a shift has operated from injectable to oral drugs over time. The proportion of patients receiving several DMTs increased with the number of available drugs. End 2018, beta interferon, glatiramer acetate, teriflunomide, dimethylfumarate, fingolimod and natalizumab shared nearly equal parts.

CONCLUSIONS

This study provides valuable insights into the real-world use of DMTs and changes that have operated over time.

Pregnancy in women with multiple sclerosis in France from 2010 to 2015: Incidence, outcomes, and exposure to disease-modifying therapies

BACKGROUND

Multiple sclerosis (MS) is usually diagnosed between 20-40 years old, when women often plan to have children.

OBJECTIVE

Our objectives were to estimate pregnancy incidence rates in women with multiple sclerosis (MS), and to describe the use of disease-modifying therapies (DMTs) before conception and during pregnancy, and pregnancy outcomes.

METHODS

This retrospective cohort study included all 15- to 49-year-old women with MS in the French national health insurance database over 2010-2015. A pregnancy was exposed if a DMT reimbursement claim occurred during pregnancy or in the 14 preceding days. We used zero-inflated negative binomial (ZINB) regression models to estimate incidence rates and ordinal and multinomial regression models to estimate DMT exposure and pregnancy outcomes.

RESULTS

The pregnancy incidence rate was 4.5 per 100 person-years. The probability of having a DMT-exposed pregnancy increased from 0.22 in 2010 to 0.30 in 2015. The probability of live birth was 0.72 (95% CI = 0.70-0.74) for exposed pregnancies (varied considerably among DMTs), 0.77 (95% CI = 0.76-0.79) without treatment, and 0.81 (95% CI = 0.79-0.83) if treatment was stopped within the previous year.

CONCLUSION

In this population-based study, we showed an increase of exposed pregnancies over time, beta-interferon and glatiramer acetate being the most used DMTs and associated with the highest probabilities of live birth. Interrupted exposed pregnancies may reflect undesired pregnancies or fear of an adverse outcome, while recent DMT stop probably reflects pregnancy planning.

Disease-modifying therapy usage in patients with multiple sclerosis in France: A 6-year population-based study

BACKGROUND

Most data regarding the use of disease-modifying therapies (DMTs) in multiple sclerosis (MS) comes from clinical series or regional databases that have a risk of recruitment bias. French health administrative data offers the significant advantage of being extensive in regards to both MS population coverage and DMT prescriptions.

OBJECTIVES

To describe patterns of DMTs usage at the level of the entire French population of MS patients from 2010 to 2015.

METHODS

MS patients were identified during a 6-year study period via the French national health data system (covering 97% of the general population) and characteristics of patients who received at least one treatment were compared to those that never received treatment over the indicated period. A state sequence analysis was performed to study in a longitudinal way MS patients who started DMTs in 2010 and then to classify them into groups of similar therapeutic patterns. DMTs were categorized into first-line, second-line and off-label use, and included untreated periods for at least six months. Groups that were obtained were described and compared using a multinomial logistic regression.

RESULTS

A total of 112,415 patients with MS were identified, of whom 54.0% received at least one DMT over the 6 years. The probability of being treated significantly decreased with age. Comorbidities and physical limitations appeared to be more frequent in not treated patients than in treated patients. Significant differences were also found between the two groups regarding the use of healthcare services (hospitalizations and visits to general practitioner, neurologist and nurse). Based on the 6-year therapeutic sequences, a four-cluster typology was obtained on the 4,474 patients who started a DMT in 2010. The first group which consisted of more than half of the patients (57.0%) mainly used first-line DMTs. The second group (13.1%) represented patients with second-line DMTs whereas the third group (7.3%) was comprised of off-label users and the last group (22.6%) was composed of MS patients who received no or minimal treatments. Classification into one of these groups was associated with patient's age, long-term disease status, pregnancy occurrence, estimated level of disability, levels of care (visits to a neurologist, nurse and/or physiotherapist and hospital/rehabilitation stays) and occurrence of death.

CONCLUSIONS

The exhaustive population-based dataset from the French national health data system gave the opportunity to provide a detailed description regarding the use of DMTs for MS at national level. The innovative method of state sequence analysis allowed obtaining four homogeneous groups of patients among thousands of longitudinal therapeutic sequences. The predominant place of first-line treatments was confirmed even if the type of first-line treatments has probably changed since 2015.

Care consumption of people with multiple sclerosis: A multichannel sequence analysis in a population-based setting in British Columbia, Canada

BACKGROUND

Persons with multiple sclerosis (PwMS) typically require complex multidisciplinary care, which is rarely formally assessed.

OBJECTIVES

We applied multichannel sequence analysis (MCSA) to identify care consumption patterns by PwMS in British Columbia, Canada.

METHODS

We created two cohorts, comprising incident and prevalent MS cases, using linked clinical and administrative data. We applied MCSA to quantify and compare the care pathways of PwMS, based on all-cause hospitalizations and physician visits (divided into five specialities). Care consumption clusters were characterized using demographic and clinical features.

RESULTS

From 1048 incident and 3180 prevalent PwMS, the MCSA identified 12 and 6 distinct care consumption clusters over a median follow-up of 9.6 and 13.0 years, respectively. Large disparities between clusters were observed; the median number of annual consultations ranged from 5.6 to 21.3 for general practitioners, 1.2 to 4.6 for neurologists and 0 to 5.3 for psychiatrists in the incident cohort. Characteristics at MS symptom onset associated with the highest care consumption included high comorbidity burden and older age. There were similar disparities and associations for prevalent PwMS.

CONCLUSION

The distinct patterns of care consumption, which were reminiscent of the heterogeneity of MS itself, may facilitate health service planning and evaluation, and provide a novel outcome measure in health research.

Incidence and prevalence of multiple sclerosis in Hungary based on record linkage of nationwide multiple healthcare administrative data

Objectives

As there were only regional studies in Hungary about the prevalence of multiple sclerosis (MS), we aimed to estimate its epidemiological features using data of Hungary’s single-payer health insurance system.

Methods

Pseudonymized database of claims reported by hospitals and outpatient services between 2004–2016 was analyzed and linked with an independent database of outpatient pharmacy refills between 2010–2016. We established an administrative case definition of MS and validated it on medical records of 309 consecutive patients. A subject was defined as MS-patient if received MS diagnosis (International Classification of Diseases, 10th edition, code G35) on three or more occasions at least in 2 calendar years and at least once documented by a neurologist. Patients were counted as incident cases in the year of the first submitted claim for MS. We allowed a 6-year-long run-in period, so only data between 2010–2015 are discussed.

Results

Sensitivity of the administrative case definition turned out to be 99%, while specificity was >99%. Crude prevalence of MS has increased from 109.3/100,000 in 2010 to 130.8/100,000 in 2015 (p-value = 0.000003). Crude incidence declined from 7.1/100,000 (2010) to 5.4/100,000 (2015) (p-value = 0.018). Direct standardization − based on European standard population and results of nationwide Hungarian census of 2011 − revealed that age standardized prevalence was 105.2/100,000 (2010), which has grown to 127.2/100,000 (2015) (p-value = 0.000001). Age standardized incidence rate declined from 6.7/100,000 (2010) to 5.1/100,000 (2015) (p-value = 0.016). The ratio of MS-patients receiving ≥1 prescription for disease modifying treatment increased from 0.19 (2010) to 0.29 (2015) (p-value = 0.0051). The female/male ratio of prevalent cases remained 2.6.

Discussion

The prevalence of MS in Hungary is higher than previously reported, the incidence rate is moderate. The prevalence is rising, the incidence rate shows decline. The proportion of patients receiving disease modifying treatment grows but was still around 30% in 2015.

Prevalence of mental disorders is higher in patients with multiple sclerosis than in the general population or in patients with rheumatoid arthritis in France

Background

Mental disorders (MDs) in multiple sclerosis (MS) patients decreases treatment adherence and quality of life, and increases the risk of disability progression and care consumption.

Objective

This study was to assess the prevalence of MDs in MS patients compared with healthy controls (HC) of the French general population and rheumatoid arthritis (RA) patients.

Methods

The 2015 prevalence of MDs for MS patients, RA patients and general population was estimated using a random population-based data sample from ‘National Inter-Scheme Information System on Health Insurance’ in the 2011–2015 period. Two control groups (1:5 ratio for the HC and 1:1 for the RA group) were matched to the MS group for year of birth, gender, area of residence and health insurance scheme.

Results

A total of 1145 MS patients were identified (sex ratio of 2.5 (F/M); median age 50 years). The prevalence of MDs was higher in the population of patients with MS (37.3%) than in the French general population (13.6%), and to a lesser extent in the RA group (21.1%) leading to the prevalence ratios of 2.8 (95% confidence intervals (CIs) 2.5–3.0) and 1.9 (95% CI 1.7–2.3), respectively.

Conclusions

This study confirmed that MS patients are at a higher risk of MDs than the French general population or RA patients.

Multiple Sclerosis in the Campania Region (South Italy): Algorithm Validation and 2015-2017 Prevalence

We aim to validate a case-finding algorithm to detect individuals with multiple sclerosis (MS) using routinely collected healthcare data, and to assess the prevalence of MS in the Campania Region (South Italy). To identify individuals with MS living in the Campania Region, we employed an algorithm using different routinely collected healthcare administrative databases (hospital discharges, drug prescriptions, outpatient consultations with payment exemptions), from 1 January 2015 to 31 December 2017. The algorithm was validated towards the clinical registry from the largest regional MS centre (n = 1460). We used the direct method to standardise the prevalence rate and the capture-recapture method to estimate the proportion of undetected cases. The case-finding algorithm including individuals with at least one MS record during the study period captured 5362 MS patients (females = 64.4%; age = 44.6 ± 12.9 years), with 99.0% sensitivity (95% CI = 98.3%, 99.4%). Standardised prevalence rate per 100,000 people was 89.8 (95% CI = 87.4, 92.2) (111.8 for females [95% CI = 108.1, 115.6] and 66.2 for males [95% CI = 63.2, 69.2]). The number of expected MS cases was 2.7% higher than cases we detected. We developed a case-finding algorithm for MS using routinely collected healthcare data from the Campania Region, which was validated towards a clinical dataset, with high sensitivity and low proportion of undetected cases. Our prevalence estimates are in line with those reported by international studies conducted using similar methods. In the future, this cohort could be used for studies with high granularity of clinical, environmental, healthcare resource utilisation, and pharmacoeconomic variables.