Decision-making in Multiple Sclerosis: The Role of Aversion to Ambiguity for Therapeutic Inertia among Neurologists (DIScUTIR MS)

Abstract

ObjectivesLimited information is available on physician-related factors influencing therapeutic inertia (TI) in multiple sclerosis (MS). Our aim was to evaluate whether physicians’ risk preferences are associated with TI in MS care, by applying concepts from behavioral economics.DesignIn this cross-sectional study, participants answered questions regarding the management of 20 MS case scenarios, completed 3 surveys, and 4 experimental paradigms based on behavioral economics. Surveys and experiments included standardized measures of aversion ambiguity in financial and health domains, physicians’ reactions to uncertainty in patient care, and questions related to risk preferences in different domains. The primary outcome was TI when physicians faced a need for escalating therapy based on clinical (new relapse) and magnetic resonance imaging activity while patients were on a disease-modifying agent.ResultsOf 161 neurologists who were invited to participate in the project, 136 cooperated with the study (cooperation rate 84.5%) and 96 completed the survey (response rate: 60%). TI was present in 68.8% of participants. Similar results were observed for definitions of TI based on modified Rio or clinical progression. Aversion to ambiguity was associated with higher prevalence of TI (86.4% with high aversion to ambiguity vs. 63.5% with lower or no aversion to ambiguity; p = 0.042). In multivariate analyses, high aversion to ambiguity was the strongest predictor of TI (OR 7.39; 95%CI 1.40–38.9), followed by low tolerance to uncertainty (OR 3.47; 95%CI 1.18–10.2).ConclusionTI is a common phenomenon affecting nearly 7 out of 10 physicians caring for MS patients. Higher prevalence of TI was associated with physician’s strong aversion to ambiguity and low tolerance of uncertainty.

Overcoming Therapeutic Inertia in Multiple Sclerosis Care: A Pilot Randomized Trial Applying the Traffic Light System in Medical Education

“…Despite significant therapeutic advances, many patients remain undertreated, especially those with chronic medical conditions, such as atrial fibrillation, hypertension, and multiple sclerosis (MS) ( 1 – 4 ). One of the explanations relates to knowledge integration and knowledge-to-action gaps in therapeutic decisions.…”

“…For example, it is known that physicians can be aware and informed about the current management of the common medical conditions they see in their daily clinical practice, but fail to integrate available information (e.g., severity of the condition, risk of progression, imaging findings, demographic factors affecting outcomes) and to implement best practice recommendations based on the available knowledge. This phenomenon may lead to therapeutic inertia (TI) usually associated with poorer outcomes ( 2 – 4 ). TI is a term that defines the absence of treatment initiation or intensification in patients when treatment goals are unmet.…”

Applying Behavioral Economics and Neuroeconomics to Medical Education and Clinical Care

“…Aversion to ambiguity in the financial domain was the most relevant predictor of TI (OR 7.39; 95% CI 1.40-38.9), followed by low tolerance to uncertainty (OR 3.47; 95% CI 1.18-10.2). 5 This finding was replicated among neurologists from Argentina and Chile (n = 115; OR for aversion to ambiguity: 2.91; 95% CI 1.06-8.04; OR for low tolerance to uncertainty: 1.47; 95% CI 1.02-2.11). Similar associations were found for stroke prevention in the management of atrial fibrillation (most common cardiac arrhythmia) among cardiologists and general practitioners.…”

“…7 Our group studied therapeutic decisions in multiple sclerosis (MS) made by neurologists applying experiments evaluating risk, ambiguity, and herding. 5 There are many treatments available for MS, ranging from low efficacy and low risk of side effects to highly efficacious agents with greater risk of severe side effects. We found that 7 out of 10 neurologists from Spain (n = 96) failed to escalate treatment when recommended by guidelines, a phenomenon called therapeutic inertia (TI).…”

“…The authors evaluated the association between risk preferences and aversion to ambiguity with physicians' responses to different simulated situations of MS patients at low, medium, or high risk of disease progression. 5 The goal of the TLS was to match case scenarios with three types of situations according to the risk of disease progression: red light (high risk of progression, "stop and think"), yellow light (intermediate risk of progression, "reassessment needed sooner than usual"), and green light (low risk of progression, "continue the same strategy"). The application of the TLS was feasible and promising by showing a trend towards a reduction in TI compared to controls (OR 0.57; 95% CI 0.26-1.22).…”