MS Patients Often Undertreated Due to Therapeutic Inertia

By Marilynn Larkin

July 26, 2019

NEW YORK (Reuters Health) - Therapeutic inertia (TI) is common among neurologists treating patients with multiple sclerosis (MS) and leads to undertreatment, researchers say.

"TI is defined as the absence of treatment initiation or intensification when treatment goals are unmet," Dr. Gustavo Saposnik of the University of Toronto, told Reuters Health by email. "This is a concept developed to explain physicians' 'status quo' in the management of patients with chronic medical conditions (and) leads to poorer patient outcomes - higher number of relapses, disability and disease burden - and suboptimal MS care."

"TI is a global phenomenon," he said. "As shown in our study, it can affect physicians from different countries, medical training, practice settings and health care systems."

Dr. Saposnik and colleagues studied TI among neurologists at academic and community centers in Canada, Argentina, Chile, and Spain. Participants were exposed to 10 MS case scenarios, eight of which required escalation of therapy. Results were used to assess aversion to ambiguity and tolerance to uncertainty.

As reported online July 17 in JAMA Network Open, 300 neurologists were invited to participate, 226 (75.3%) agreed, and 195 (86.3%) completed the study: 55 in Canada, 90 in Argentina, 25 in Chile, and 25 in Spain. Neurologists' mean age was 43 and 52% were men.

TI was identified in 72.8% of participants, leading to suboptimal decisions in 20.4% of case scenarios. TI prevalence was lowest in the Canadian group: 60% versus 77.9% in the other countries.

A TI score was calculated by dividing the number of case scenarios in which participants showed TI by 8 (the number of case scenarios that measured TI).

On a scale of 0 to 8, scores were significantly lower in the Canadian group (mean 0.98) compared with other countries: mean 1.70 for Argentina, 2.24 for Chile, and 2.56 for Spain. Further analyses showed that participants from Argentina, Chile, and Spain combined had higher TI scores compared with their Canadian counterparts.

Overall, factors associated with a lower likelihood of TI included a higher number of patients with MS per week (OR, 0.44), years of practice (OR, 0.93), and participation from Canada (OR, 0.47).

Aversion to ambiguity was associated with a 2-fold higher likelihood of TI (OR, 2.25).

Factors leading to TI may include physicians' limited training in risk management and formal education in decision making, as well as decision fatigue, Dr. Saposnik noted. His team developed and tested an educational intervention applying a "traffic-light" system that reduced TI among participating neurologists by 70% compared to controls. ( They are now testing models using concepts from artificial intelligence.

Dr. Louis Goodrich, Assistant Professor of Clinical Neurology at the Lewis Katz School of Medicine at Temple University in Philadelphia, commented by email, "We certainly see TI in the treatment of MS patients (and) it is not surprising that more experienced physicians had lower TI."

That said, he told Reuters Health, "It is not clear from the article that these results can be extrapolated to the U.S., given our different system of healthcare delivery."

"As the landscape of MS treatments continues to evolve, we should continue to improve our ability to control patients' disease," he said. "Higher-efficacy therapies, however, come with unique associated risks. Thus, the more options we have for treating this disorder, the more challenging it becomes to select the appropriate treatment, especially for physicians who do not use these drugs regularly."

"We need to be mindful of our definition of 'success' in treating MS," he noted. "With so many treatment options, we should not accept clinical or radiologic disease activity unless we have exhausted all available options."

"Keeping a patient on a suboptimal treatment because it is well tolerated is not without its own risks," he added, "especially since we do not yet have therapies to reverse disability once it has accumulated."

Dr. Rock Heyman, Chief of the Division of Multiple Sclerosis and Neuroimmunology at the University of Pittsburgh Medical Center, commented in an email to Reuters Health, "TI is indeed an issue in MS care (and) is especially important because the best opportunity to control the disease is early on, before major disability is present."

"Clinicians should be aware that growing data shows that the newer agents have a greater efficacy for people with all levels of MS and not reserve the more potent agents for only those who have more severe disease," he said. "As was shown in a recent European study, early intensive disease modifying therapy in MS may have big benefits compared to a platform approach which uses less potent agents first." (

The study was funded by Roche. Dr. Saposnik and five coauthors have various forms of financial ties to the company.


JAMA Netw Open 2019