Socioeconomic status and disease-modifying therapy prescribing patterns in people with multiple sclerosis

Socioeconomic, health-care access and clinical determinants of disease severity in Multiple Sclerosis in Chile

BACKGROUND

MS severity may be affected by genetic, patient-related, disease-related and environmental factors. Socioeconomic status, including income and healthcare access, amongst others, may also have a role in affecting diagnostic delay or therapy prescription. In Chile, two main healthcare systems exist, public-healthcare and private-healthcare, nonetheless universal care laws (e.g., access to High Efficacy Therapy-HET), including both systems, have been recently enacted for people with MS.

OBJECTIVE

To assess the role of Socioeconomic Conditions (SEC), clinical variables and public health policies on the impact of disease severity of MS patients in Chile.

METHODS

Multicentric, observational, cross-sectional study including patients from two reference centres (1 national reference centre from the private-health system and 1 regional reference centre from the public-health system). SEC and clinical variables included healthcare insurance (private or public), subclassification of health insurance according to monthly income, sex, age at onset, diagnostic delay, disease duration, diagnosis before HET law (as a proxy of HET delay), and current HET treatment. Progression Index (PI), EDSS ≥6.0 and Progressive MS diagnosis were used as outcome measures. Multivariable binary logistic regression was performed.

RESULTS

We included 604 patients (460 private-health, 144 public-health), 67% women, 100% white/mestizo, 88% RRMS, mean age 42±12 years, mean age at onset 32±11 years, mean disease duration 10±6 years, median diagnostic delay 0 (0-34) years, 86% currently receiving any DMT, 55% currently receiving HET, median EDSS at last visit of 2.0 (0-10), and median PI 0.17 (0-4.5). Lower monthly income was associated with higher EDSS and higher PI. In the multivariable analysis, public-healthcare (OR 10.2), being diagnosed before HET-law (OR 4.89), longer diagnostic delay (OR 1.26), and older age at onset (OR 1.05) were associated with a higher risk of PI>0.2, while current HET (OR 0.39) was a protective factor. Diagnosis before HET-law (OR 7.59), public-healthcare (OR 6.49), male sex (OR 2.56), longer disease duration (OR 1.2) and older age at onset (OR 1.1) were associated with a higher risk of Progressive MS. Public-healthcare (OR 5.54), longer disease duration (OR 1.14) and older age at onset (OR 1.08) were associated with a higher risk of EDSS ≥6.0 while current treatment with HET had a trend as being a protective factor (OR 0.44, p = 0.05).

CONCLUSION

MS severity is impacted by non-modifiable factors such as sex and age at onset. Interventions focused on shortening diagnostic delay and encouraging early access to high-efficacy therapies, as well as initiatives that may reduce the disparities inherent to lower socioeconomic status, may improve outcomes in people with MS.

social determinants of health in multiple sclerosis

Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants — that is, the ‘risks of risks’ — on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed.

Here, the authors discuss the potential effects of social determinants of health on multiple sclerosis risk and outcomes. They suggest that addressing these determinants of health could substantially improve the lives of individuals with multiple sclerosis and call for more research.

Addressing an individual’s social determinants of health — that is, the conditions under which they are born, grow, live, work and age — could provide opportunities to reduce the burden of living with multiple sclerosis (MS).

Individual factors that may influence MS-related outcomes include sex, gender and sexuality, race and ethnicity, education and employment, socioeconomic status, and domestic abuse.

Societal infrastructures, including access to food, health care and social support, can also affect MS-related outcomes.

Awareness of the specific circumstances of a patient with MS might help neurologists deliver better care.

Social determinants of health are not static and can change according to wider sociopolitical contexts, as highlighted by the COVID-19 pandemic.

Rigorous studies of interventions to ameliorate the effects of poor social determinants on people with MS are urgently needed.

The association between deprivation and the access to disease modifying therapies for multiple sclerosis: An England wide community-based study in the UK MS Register

BACKGROUND

Deprivation can impact the access to health interventions in publicly funded health systems where cost is not the dominant barrier. In this study we examined whether deprivation affected the access to disease modifying therapies (DMTs) for multiple sclerosis (MS).

METHODS

All English adults on the UK MS register with relapsing remitting MS who were diagnosed between 2010 and 2017, and after the age of 29 years were included. Deprivation was measured using postcode-based 2015 English index of multiple deprivation (IMD), which was divided into quintiles.

RESULTS

A total of 1449 participants were eligible and 531/1449 (36.6%) received DMTs. Participants who lived in more deprived areas, based on their IMD scores, were significantly less likely to receive DMTs (odds ratio = 0.69, 95% Confidence interval = 0.49 to 0.98); barriers to housing and services contributed to this disparity. The Nagelkerke R² value of these models showed that 2% of variation in accessing DMTs were dependant on deprivation.

CONCLUSIONS

Deprivation, as measured by IMD, negatively influences the access to DMTs in England. Our findings also suggest that the lack of access to local MS DMT clinics in deprived areas may contribute to this disparity.

Socioeconomic disadvantage in multiple sclerosis: does inequality act on the substrate for disability?

This scientific commentary refers to ‘Socioeconomic disparity is associated with faster retinal neurodegeneration in multiple sclerosis’ by Vasileiou et al. (doi:10.1093/brain/awab342).