RESUMEN
OBJECTIVE: To design and implement a health system level intervention to reduce escalating multiple sclerosis (MS) disease modifying treatment (DMT) expenditures and improve outcomes. METHODS: We conducted stakeholder meetings, reviewed pharmacy utilization data, and abstracted information in subsets of persons with MS (pwMS) from the electronic health record to identify gaps in, and barriers to improving, quality, and affordability of MS care in Kaiser Permanente Southern California. These results informed the development and implementation of the MS Treatment Optimization Program (MSTOP). RESULTS: The two main gaps identified were under-prescribing of highly effective DMTs (HET, 4.9%) and the preferred formulary DMT (20.9%) among DMT-treated pwMS. The main barriers identified were prescribers' fear of rare but serious HET side effects, lack of MS-specific and health systems science knowledge, Pharma influence, evidence gaps, formulary decisions-based solely on costs, and multidirectional mistrust between neurologists, practice leaders, and health plan pharmacists. To overcome these barriers MSTOP developed four strategies: (1) risk-stratified treatment algorithm to increase use of HETs; (2) an expert-led ethical, cost-sensitive, risk-stratified, preferred formulary; (3) proactive counter-launch campaigns to minimize uptake of new, low-value DMTs; and (4) discontinuation of ineffective DMTs in progressive, non-relapsing MS. The multicomponent MSTOP was implemented through education, training, and expanding access to MS-trained providers, audit and feedback, and continual evidence reviews. INTERPRETATION: The causes of wasteful spending on MS DMTs are complex and require multiple strategies to resolve. We provide herein granular details of how we designed and implemented our health system intervention to facilitate its adaption to other settings and conditions.
Asunto(s)
Prescripciones de Medicamentos/economía , Agentes Inmunomoduladores/economía , Agentes Inmunomoduladores/uso terapéutico , Esclerosis Múltiple/tratamiento farmacológico , Esclerosis Múltiple/economía , Calidad de la Atención de Salud , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Desarrollo de ProgramaRESUMEN
OBJECTIVE: The prevailing approaches to selecting multiple sclerosis (MS) disease modifying therapies (DMTs) have contributed to exponential increases in societal expenditures and out-of-pocket expenses, without compelling evidence of improved outcomes. Guidance is lacking regarding when and in whom the benefits of preventing MS-related disability likely outweighs the risks of highly effective DMTs (HET) and when it is appropriate to consider DMT costs. Our objective was to develop a standardized approach to improve the quality, affordability and equity of MS care. METHODS: MS experts partnered with health plan pharmacists to develop an ethical, risk-stratified, cost-sensitive treatment algorithm. We developed a risk-stratification schema to classify patients with relapsing forms of MS as high, intermediate or low risk of disability based on the best available evidence and, when the evidence was poor or lacking, by consensus. DMTs are grouped as highly, modestly or low/uncertain effectiveness and preferentially ranked within groups by safety based on pre-specified criteria. We reviewed FDA documents and the published literature. When efficacy and safety are equivalent, the lower cost DMT is preferred. RESULTS: Assignment to the high-risk group prompts treatment with preferred HETs early in the disease course. For persons in the intermediate- or low-risk groups with cost or health care access barriers, we incorporated induction therapy with an affordable B-cell depleting agent. Based on more favorable safety profiles, our preferred approach prioritizes use of rituximab and natalizumab among HETs and interferon-betas or glatiramer acetate among modestly effective agents. INTERPRETATION: The risk-stratified treatment approach we recommend provides clear, measurable guidance in whom and when to prescribe HETs, when to prioritize lower cost DMTs and how to accommodate persons with MS with cost or other barriers to DMT use. It can be adapted to other cost structures and updated quickly as new information emerges. We recommend that physician groups partner with health insurance plans to adapt our approach to their settings, particularly in the United States. Future studies are needed to resolve the considerable uncertainty about how much variability in prognosis specific risk factors explain.