Objective

The increasing variety of disease-modifying therapies (DMTs) and the lack of current treatment guidelines in multiple sclerosis (MS) challenge neurologists to make appropriate treatment decisions as they weigh such factors as drug safety and efficacy, disease activity, and patient characteristics.1-3 The aim of this study was to determine whether an online CME intervention addresses this gap by measuring the impact of education using a performance-level assessment of neurologists in the United States (US) and outside the US (OUS).

results

Methods

The effectiveness of an online educational intervention focusing on the science and impact of novel DMTs for MS was analyzed using a case-based pre-assessment/post-assessment study design.

InstructIonal Method:

• The instructional format consisted of an interactive, 5000-word text-based CME activity for the target audience of neurologists.4

◦ This format distills detailed information into easily digestible segments and is designed to provide clinical context and perspective on new developments in MS.

• The activity included interactive, multiple-choice, intra-activity questions to provide elements of engagement and feedback.

• The activity was available on the Medscape Mobile application, ensuring real-time access by the many clinicians who rely on mobile devices for education.

assessMent Method: • The outcomes survey method to measure performance included

knowledge- and case-based multiple-choice questions that mirror clinical encounters and the elements needed for decision making derived from current evidence-based recommendations.

• Confidentiality of survey respondents was maintained and responses were de-identified and aggregated prior to analysis.

• Non-practicing clinicians and clinicians not involved in the care of patients with MS were excluded from the study.

• Responses to questions associated with the clinical cases were collected and compared with baseline data (collected prior to participation in the educational intervention) in order to assess the effect of the education.

• Chi-square tests were conducted to detect differences between the baseline and the post-education assessment responses among neurologists. The level of statistical significance for analytical tests was set at P<.05.

• Overall mean scores and pooled standard deviations were calculated for the aggregated participant pre- and post-assessment survey responses. Cohen’s d was used to calculate the effect size of the intervention. Effect sizes greater than 0.8 are large, between 0.8 and 0.4 are medium, and less than 0.4 are small.

Impact of Global Education on Decision Making Related to Disease-Modifying Therapy in Multiple Sclerosis

• A total of 551 US and OUS neurologist learners participated in the educational activity. The study sample consists of 160 neurologists who completed the outcomes assessment (Figure 1).

• Neurologists (N=160) were 35.6% (moderate effect size d=0.55) more likely to make evidence-based practice choices after participation in the activity.

◦ Specifically, US neurologists (n=47) were 20% (effect size d=0.28) more likely and OUS neurologists (n=113) were 41.1% (effect size d=0.66) more likely to make evidence-based practice choices after participation in the activity.

• Specific areas of improvement included:

◦ Awareness of the pregnancy risk of several MS DMTs (US, P=.25; OUS, P<.001) (Figure 2)

◦ Counseling patients about adverse

effects of dimethyl fumarate (DMF) (US, P=.01; OUS, P=.004) (Figure 3)

◦ Recognizing Goodpasture syndrome

as a potential adverse event of alemtuzumab (US, P=.003; OUS, P<.001) (Figure 4)

◦ Counseling patients about adverse

effects of fingolimod (US, P=.06; OUS, P<.001) (Figure 5)

Assessment respondents by region.

Africa

Asia

Europe

Latin America

North America

Oceania

16%

38%

10%

34%

1% 1%

Ron Schaumburg, MA, Medscape, LLC, New York, NY; Stephen Krieger, MD, Icahn School of Medicine at Mount Sinai, New York, NY

References

Scan here to view this poster online.

Case: After discussing treatment options, you and the patient decide that she should begin DMF before she is ready to get pregnant. She experiences prominent flushing and cramping/frequent diarrhea within the second week of initiating therapy with the starting dosage of 240 mg twice a day.

Case #1:

Case #1 (cont):

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

Overall P<.001*US neurologists P=.25OUS neurologists P<.001*

US Pre (n = 47)US Post (n = 47)

OUS Pre ( n = 113)OUS Post ( n = 113)

Glatiramer acetate is pregnancy category C

and should not be used during pregnancy

Dimethyl fumarate (DMF) is pregnancy category B and can safely be used

during pregnancy

Contraception should be continued for two months following discontinuation

of fingolimod before becoming pregnant*

Contraception should be continued for two months

following discontinuation of teriflunomide before becoming pregnant

12%

23%26%

17%11%

34%43%

26%21%

5%

35%

22%30%

55%

22% 18%

Awareness of the pregnancy risk of several MS DMTs.

Which of the following statements would you consider when selecting a treatment agent for this patient? (select only 1)

Figure 2:

Case: A 37-year-old woman with MS has been treated with high-dose interferon for the past 6 years. She had a mild relapse 2 years ago but has been clinically doing well since then. On a recent MRI, she has 5 gadolinium-enhancing lesions. You discuss switching therapies and discover that she is JC virus antibody positive with a titer of 3.1. She is interested in other agents with high efficacy.

Case #2:

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

Overall P<.001*US neurologists P=.06*OUS neurologists P<.001*

US Pre (n = 47)US Post (n = 47)

OUS Pre ( n = 113)OUS Post ( n = 113)

An EKG is required if her resting heart rate is less than 50 beats per

minute

Fingolimod has no head-to-head data, so we cannot speak as to how

efficacious it is related to other therapies

Patients taking fingolimod may develop herpes zoster infection*

Blurred vision is a known side effect, and should not be cause for alarm

40%

19%

41%

38% 38%49%

35%

9%

13%

42%

2% 4%

4%4% 2%

59%

Counseling patients about adverse effects of fingolimod.

Which of the following pertains to counseling her about fingolimod? (select only 1)

Figure 5:

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

Overall P<.001*US neurologists P=.01*OUS neurologists P=.004*

US Pre (n = 47)US Post (n = 47)

OUS Pre ( n = 113)OUS Post ( n = 113)

Slightly greater than 75% of patients have

flushing and GI symptoms

Tell her that it may take several weeks or months

for the side effects to abate*

Based upon the long half-life of DMF, she

would be fine taking it once per day

27% 27%

32%38%

26%

11%

39%

57%

55%

30%

19% 20%

Advise her that DMF is unlikely to be tolerated,

and she should switch to an alternative

4%

6% 6%

2%

Counseling patients about adverse effects of DMF.

How would you counsel the patient about the adverse effects she is experiencing? (select only 1)

Figure 3:

100%

80%

60%

40%

20%

0%

100%

80%

60%

40%

20%

0%

Overall P<.001*US neurologists P=.003*OUS neurologists P<.001*

US Pre (n = 47)US Post (n = 47)

OUS Pre ( n = 113)OUS Post ( n = 113)

Progressive multi-focal leukoencephalopathy

Goodpasture syndrome* Increased risk of leukemia

Increased risk of diastolic dysfunction

47% 49%

28%

34%

40%

13%

23%

9%

41%

78%

21%

2% 2%

4% 1%8%

What complications have been seen with alemtuzumab? (select only 1)

Figure 4: Recognizing Goodpasture syndrome as a potential adverse event of alemtuzumab.

Case: A 26-year-old woman presents with mild optic neuritis with a diagnosis of MS confirmed by a brain MRI that revealed 5 T2 lesions, 2 of which were presently enhancing. Three months prior, she had an episode of left leg numbness that lasted a week. She is interested in starting a treatment, but would like to start a family in the next 1 to 2 years.

This study demonstrated the success of a targeted educational intervention on improving the knowledge and case-based performance of US and OUS neurologists regarding decisions about new DMTs in MS. These statistically significant improvements provide strong evidence that well-designed online text-based instruction is a useful methodology for knowledge transfer among neurologists. In particular, an increase in neurologists’ awareness of adverse events associated with new MS DMTs has the potential to improve the monitoring for and mitigation of these risks in clinical practice.

1. Brück W, Gold R, Lund BT, et al. Therapeutic decisions in multiple sclerosis: moving beyond efficacy. JAMA Neurol. 2013;70:1315-1324.2. Hanson KA, Agashivala N, Wyrwich KW, Raimundo K, Kim E, Brandes DW. Treatment selection and experience in multiple sclerosis: survey of neurologists. Patient Prefer

Adherence. 2014;8:415-422.3. Tornatore C, Phillips JT, Khan O, Miller AE, Barnes CJ. Practice patterns of US neurologists in patients with CIS, RRMS, or RIS: a consensus study. Neurol Clin Pract.

2012;2:48-57.4. Buttmann M. Novel Therapies for MS, Part 1: The Science and Impact of Oral MS Therapies. April 25, 2014.

http://www.medscape.org/viewarticle/823890. Accessed March 15, 2015.

Acknowledgements The educational intervention and outcomes measurement were funded through an independent educational grant from Biogen. For more information, contact Ron Schaumburg, Scientific Director, Medscape, LLC, rschaumburg@medscape.net.

Conclusions

Figure 1: