Medical Education for Better Multiple Sclerosis Outcomes
Condition: Multiple Sclerosis
MeSH terms: Multiple Sclerosis; Sclerosis
Study type: Interventional

Summary: 
      The main objectives of this study are:

      i) To design an educational tool to train physicians in overcome cognitive factors associated
      with therapeutic inertia.

      ii) To determine the feasibility and efficacy of an educational tool to overcome therapeutic
      inertia among neurologists caring for MS patients

      iii) identify the best strategy to disseminate an educational program to train physicians
      taking into account regional and practice variations.

      iv) To explore whether multiple sclerosis (MS) patients' risk category influence the
      incidence of therapeutic inertia in neurologists that may require a segmentation strategy in
      medical education.

      v) To assess how participants handle uncertainty when making treatment decisions by measuring
      pupil variation from baseline (Canadian study).

      vi) To evaluate the effect of the TLS on TI by assessing differences pupil variability
      between the intervention and control groups (Canadian study).

      A multicenter, randomized, study including an educational intervention (applying the traffic
      light system) to overcome therapeutic inertia in MS care.
    

Detailed description: 
      The goal of the present study is the application of an educational intervention (based on
      best clinical practices) to reduce therapeutic inertia targeting neurologists caring for MS
      patients. The investigators are also interested in evaluating whether an education
      intervention decreases TI by reducing arousal response (pupil dilation), a proxy measure of
      how physicians respond to uncertainty during treatment decisions.

      A secondary goal is to improve physicians' tolerance to uncertainty, which has been directly
      related to therapeutic inertia in our previous studies. This proposal follows the results of
      our study that identified factors associated with management errors and therapeutic inertia
      by applying novel concepts and validated experiments from Behavioral economics/
      Neuroeconomics.

      Rationale for the current study:

        -  Physicians have limited education in risk management and formal training in decision
           making.

        -  Only a small proportion of MS patients are being treated according to the best clinical
           practice guidelines. Physicians (cognitive biases affecting decision making) and health
           system (e.g. access to an infusion center) factors are the most responsible causes of
           practice gaps in MS care (Blum).

        -  In a previous study (JURaSSiC), physicians have shown poor estimation of the prognosis
           of stroke patients. As this not unique to a single neurological condition and directly
           affects the recognition of patients who would benefit from escalating therapies.

        -  Therapeutic inertia (TI) is a common phenomenon in medicine defined as lack of treatment
           escalation when recommended according to the best practice guidelines. This phenomenon
           lead to poorer patients outcomes, greater disability, and diminished quality of life.

        -  In a recent study conducted by our group including 136 neurologists and MS experts, the
           investigators found TI was present in nearly 7 out of 10 (68.8%) of participants.
           Similar results were observed for criteria of disease progression. Aversion to ambiguity
           (situation when risk are unknown) and low tolerance to uncertainty were the stronger
           predictors of TI among neurologists caring for MS patients.

        -  Although risk prognostic tools (e.g. EMA, modified Rio, clinical+radiological
           progression) are available to assist physicians in stratifying patients, it is not known
           whether or not neurologists use a systematic approach to improve the therapeutic
           decisions in MS care.

        -  There is a limited understanding on how to ameliorate the physicians' factors (e.g. low
           tolerance to uncertainty, aversion to ambiguity, etc) associated with TI, which leads to
           worse clinical outcomes and poor quality of life.

      Some strategies has been proposed to reduce the effects cognitive factors and biases on
      clinical decisions. A comprehensive narrative review comprising 41 studies on cognitive
      interventions to reduce misdiagnosis found three main effective strategies: increasing
      knowledge and expertise, improving clinical reasoning, and getting help from colleagues,
      experts and tools.18 First, reflective reasoning counteracts the impact of cognitive biases
      by improving diagnostic accuracy in second- (OR 2.03; 95%CI, 1.49-2.57) and first-year
      residents [OR (odds ratio) 2.31; 95% CI, 1.89-2.73].19 Second, the implementation of tools
      (e.g. cognitive checklist, calibration) may overcome overconfidence, the anchoring and
      framing effects (figure 5).20-22 Third, heuristics approaches (shortcuts to ignore less
      relevant information to overcome the complexity of some clinical situations) can improve
      decision making. As shown by Marewski and Gigerenzer, the identification of three rules
      (search for predictors to determine their individual importance, stop searching when relevant
      information was already obtained, and a criteria that specify how a decision is made) may
      facilitate prompt decisions and may help physicians to avoid errors in some clinical
      situations.

      The inclusion of training in cognitive biases in graduate and postgraduate programs might
      foster medical education and thereby improve health care delivery.

      In summary, a new arsenal of disease-modifying agents became available in the last few
      decades (and more will be approved in the next three years), but over half of neurologists
      caring for MS patients do not escalate therapy when indicated by clinical best practices. As
      such, physicians' decision-making process and access to new effective DMTs became the current
      bottleneck in MS care. Physicians' factors that are directly associated with therapeutic
      inertia in MS care. The investigators propose to creating and testing an intervention or tool
      to train physicians to overcome biases, implement more standardized therapeutic approaches,
      which will lead to reducing the incidence of TI and better MS outcomes.
    

Intervention name(s): Educational intervention applying the traffic light system (TLS)
Intervention type(s): Behavioral
Intervention description(s): The TLS emerged to facilitate consumers' decisions. It has been applyied in medical decision making.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Supportive Care
Keywords: neuroeconomics; multiple sclerosis; educational intervention; traffic light system; aversion to ambiguity; risk; outcomes; knowledge; action; gaps; disease modifying agents