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Factors affecting DMD prescribing in the UK

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Summary

The number of people taking disease modifying drugs in the UK is lower than in other European countries; within the UK there is variation in prescribing rates and the range of drugs offered between the home nations and at the regional level. Despite this, very little research has been done to understand the factors that might influence health professionals’ prescribing.

This study interviewed 18 neurologists and 16 MS specialist nurses from different settings across the four UK nations. Analysis of the interviews revealed several factors that influenced decision making and prescribing:

Prescribing guidelines: for example those drawn up by NICE, set out NHS eligibility criteria for the DMDs. On the whole, neurologists in England felt more restricted by these than their colleagues in Scotland, Wales and Northern Ireland.

Identifying relapses: eligibility for DMDs is based on frequency and severity of relapses, so accurately identifying relapses is critical. Interviewees reported that this is not always straightforward and definitions are open to interpretation.

Attitudes to risks and benefits: neurologists differed in their attitudes to risks and benefits of DMDs. Active prescribers were willing to prescribe more effective DMDs with greater risk of side effects when necessary. More conservative prescribers were less convinced about long term effectiveness and worried about the risk of serious side effects of DMDs.

Familiarity and prior experience: not surprisingly, neurologists prescribed DMDs that they were most familiar with, particularly if they had been involved in a clinical trial.

Peer networks and prescribing cultures: prescribing habits of colleagues locally and nationally as well as the local team’s prescribing culture were also important influences.

The study has identified some of the factors that contribute to variation in prescribing of DMDs in the UK. The researchers make a number of recommendations including more open acknowledgement of individual differences in health professionals’ attitudes to prescribing DMDs and the impact this has on equitable access to DMDs regardless of location.


Background

The proportion of people with relapsing remitting MS taking disease modifying drugs (DMDs) in the UK is considered low compared with other countries; in 2013, 59% of people with RRMS in the UK were prescribed DMDs compared with rates ranging between 75% and 91% in Sweden, Italy, Spain Germany and France. In the UK, there are also differences in DMD prescription rates both nationally (England, Wales, Scotland, and Northern Ireland) and regionally. Despite this, there has been little research into the factors that influence health professionals’ prescribing practices.

The aim of this study was to investigate the views and experiences of neurologists and MS nurses to get a better picture of the factors that influence their prescribing patterns.

How this study was carried out

Researchers carried out interviews with 18 neurologists and 16 MS specialist nurses from different settings across the four UK nations. Interviews were recorded and analysed to identify underlying themes.

What was found

Analysis of the interviews revealed several factors affecting prescribing decisions:

  • Prescribing guidelines

Neurologists in England felt more restricted by guidelines such as those drawn up by NICE. They felt that their decisions were accountable for at a national level which gave them limited opportunity for discussion. In general, neurologists in Scotland, Wales and Northern Ireland felt they had greater flexibility and were able to justify decisions locally, giving them greater opportunity for dialogue.

  • Identifying relapses

Eligibility for DMDs is based on frequency and severity of relapses, but both neurologists and MS nurses reported difficulties in distinguishing a true relapse from a temporary flare-up (pseudo-relapse) of symptoms. Some definitions, such as “disabling relapse” were open to interpretation. MS nurses in particular stressed the importance of accurate identification of true relapses which could be difficult when assessments were carried out over the phone or when relapses were reported after the event at annual review appointments.

  • Perceived risk and readiness to prescribe

Neurologists had different attitudes towards risks and benefits. Some described themselves as an “active prescriber” and “fairly aggressive when it’s needed” while others “took a more careful approach” particularly when considering prescribing DMDs with greater risk of side effects. The more conservative prescribers were not convinced about the longer term effectiveness of DMDs on disability and were uncertain about the need for treatment given the unpredictable nature of MS. In contrast, more proactive prescribers were concerned that people might do worse than expected if they were not on more effective treatments.

  • Familiarity and prior experience

Interviewees said they were most likely to prescribe a DMD that they were familiar with which was related to the number of people prescribed the drug so far and whether they or their service had been involved in the drug’s clinical trials. Positive and negative experiences from people taking one of the drugs also affected confidence in prescribing and recommending DMDs.

  • Peer networks and prescribing cultures

Prescribers were influenced by what colleagues were doing locally and nationally. In some centres, neurologists worked within a multidisciplinary team to develop a standardised approach to prescribing DMDs. In other centres, prescribing patterns could be influenced by strongly expressed views of local opinion leaders.

What does it mean?

The study has identified some of the factors that contribute to variation in prescribing of DMDs in the UK. The researchers make a number of recommendations including more open acknowledgement of differences in health professionals’ attitudes to prescribing DMDs and how this affects equitable access to DMDs regardless of location. Strengthening peer networks would improve confidence in prescribing the full range of DMDs, particularly for smaller centres and general neurologists who prescribe DMDs.

Cameron E, et al.
Factors influencing multiple sclerosis disease-modifying treatment prescribing decisions in the United Kingdom: A qualitative interview study.
Multiple Sclerosis and Related Disorders 2019; 27: 378-382.
Abstract 
Full study 

More about choosing a disease modifying drug

In the UK, there are currently 13 disease modifying drugs approved for use in the NHS for people with relapsing remitting MS.  You can read more about the drugs in MS Decisions and our booklet Disease modifying drugs: a guide to treatments for relapsing MS.  

Your MS team will tell you if you are eligible for DMDs and if so which ones would be suitable for you and your MS. They will make recommendations based on how active your MS has been, the number of relapses you have had and how these have affected you. When prescribing a DMD, your MS team has to work within NHS eligibility criteria which define the type of MS the drug can be used for.

NICE  (National Institute for Health and Care Excellence) appraises new medicines for England and Wales. They look at the evidence on how well a new DMD works, any drawbacks or limitations the drug may have and the cost effectiveness of treatment. In Scotland, appraisal is carried out by SMC (Scottish Medicines Consortium). NICE guidance is reviewed and adapted for use in Northern Ireland.  

Other organizations may also influence a drug's availability within the NHS. To guide prescribing, NHS England has published a commissioning policy and a treatment algorithm for the DMDs and requires neurologists to enter details of each prescription into Blueteq, an online system for managing high cost drugs.  The AWMSG (All Wales Medicines Strategy Group) may appraise a new drug if NICE is not expected to carry out an assessment within the next twelve months. The ABN (Association of British Neurologists) has published guidelines for prescribing DMDs in the UK.

Like you, your MS team will have their own opinions and views on the best course of action to take. They may weigh up the pros and cons of each option in a different way to you and will have a different perspective. Their own views of risks and benefits may influence how cautious their recommendations are. Some might suggest a riskier course of action for bigger benefits and some may have a much more cautious approach. Their views will be based on their own experiences and knowledge of MS. 

Your MS team is there to support you in the management of your MS, so do take account of their advice but feel free to ask them questions or challenge their choices if you have any concerns.  You can find sample questions to ask in questions to ask your health professionals.

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