International Consensus on Timely Care for Multiple Sclerosis

A panel of multiple sclerosis (MS) neurologists developed an internationally applicable standard of care for timely management in patients with MS.

MS is a progressive neurological disease that requires timely management. Once neurons die, they cannot be replaced; thus, preservation strategies are of upmost importance. Quality standards and early treatment have shown to be crucial in treating MS. However, formalized standards have been lacking, causing disparities in care. To help reform this issue, a panel of neurologists participated in the Delphi process to standardize timely care for patients with MS.

The Delphi process consisted of 27 neurologists on the Delphi panel, 21 of whom completed the consensus. Areas of interest in timely management of MS included referral and diagnosis, priorities following diagnosis, routine monitoring and support, treatment decisions, and new symptoms. Each category was divided into 3 standard levels: core, achievable, and aspirational. Core constitutes to a level that should be achieved by most MS teams (minimum standard), achievable is a realistic target for most MS teams (standard of care), and aspirational should be achieved in advanced MS teams (high-quality care).

The difference between the 3 standard levels is in the time frames of care. For example, referral to a neurologist should be done in 4 weeks at the core level, but 10 days at the achievable level, and 4 days the aspirational level. These differences in time frame are meant to accommodate for the varying healthcare centers in the world and what tools they have in providing care.

Achievable standards of care for MS reflects good standard of care and the timings for each step is emphasized by the Delphi panel. Patients who experience their first symptoms related to MS should go to their primary physician within 10 days. Within the next 10 days, the primary physician should refer the patient to a neurologist. The neurologist should complete a magnetic resonance imaging (MRI) scan within 2 weeks and all diagnostic workup and provide an accurate diagnosis within 4 weeks. Once the diagnostic workup is complete, the neurologist should discuss the results with the patient within 10 days, and if the patient is diagnosed with MS, he or she should be offered an initial appointment of at least 45 minutes.

Once the diagnosis of MS is made, the MS team should discuss treatment goals within 2 weeks, the importance of brain-healthy lifestyle within 4 weeks, and offer referrals for any additional lifestyle modification support that the patient may need within 3 months. The team should also check if the patient is eligible for a suitable disease-modifying therapy (DMT) and discuss the advantages and disadvantages of DMTs within 3 weeks of diagnosis. Routine evaluations of DMT, brain-healthy lifestyles, and comorbidity screenings should be done every 6 months, with a MRI scan offered every year.

Treatment decisions should also not be delayed in MS. Previous randomized clinical trials have found that early treatment with DMT was associated with better outcomes, specifically lower relapse rates. Once a patient is eligible for a DMT, he or she should be offered 1 within 3 weeks. Patients who agree to receive a DMT should be prescribed 1 within 2 weeks. Any patients who have suboptimal response to DMT should be offered an alternative DMT within 4 weeks. Patients who report new symptoms should report to their MS team within 7 days. The MS team should respond within 2 days and the patient should be seen within 3 days.

Timely management of MS leads to better outcomes and leads to less acute deterioration of the disease. Although the time frames for achievable level of care is not something every healthcare center can do, it is something to reach for and maintain.

Reference

Hobart J, Bowen A, Pepper G, et al. International consensus on quality standards for brain health-focused care in multiple sclerosis [published online November 1, 2018]. Mult Scler. doi: 10.1177/1352458518809326.