Multicentre audit on the use of MRI in the management of patients with MS – call for volunteers

Linford Fernandes, Christopher Allen and Thomas Williams

The UK MS Trials and Registries Consortium is piloting the first national audit on the use of MRI in patients with MS and are looking for volunteers interested in auditing their centre’s practice. The aim is to reach as many MS centres as possible to establish current UK practice, as compared to international guidelines.

For those interested in service improvement there is the possibility to then work with colleagues nationally to harmonise practice and maximise the impact of your efforts. The audit protocol and data capture tool will be distributed directly with volunteers. All those contributing data will be recognised with authorship in any output(s) and will receive a copy of the national dataset.

If interested please contact linford.fernandes@nhs.net for the audit toolkit.

Background

MRI has an important role in the diagnosis and management of patients with multiple sclerosis (MS). MRI is used routinely in clinical practice to establish the diagnosis and disease burden and inform prognosis of MS patients. It is also used to monitor response to disease modifying treatment (DMT) and provides a tool to measure disease activity. Finally, it plays a crucial safety role in the pharmacovigilance for certain DMTs.

There are no widely implemented UK national consensus guidelines on the use of MRI in the management of patients with MS, but efforts have been made to begin this process.¹ NICE guidance on the management of MS in adults, briefly mentions MRI in the context of the diagnostic process.² MAGNIMS published consensus recommendations on the use of MRI in the monitoring of patients with MS in 2015.³ More recently, a consortium of MS centres produced revised technical guidelines on the MRI protocols for monitoring in MS in different clinical contexts.⁴

Aim

This retrospective multicentre UK audit aims to identify the current use of MRI in the monitoring and management of patients with MS and how this compares to available guidelines.

Method

Please follow your organisation’s local process for registering the audit prior to data collection. Please also notify linford.fernandes@nhs.net of your intention to participate in the audit. This will ensure the same audit is not performed twice at the same centre.

Audit 100 consecutive MS cases seen in clinics run by MS doctors and MS nurses from 1^st September 2019. If MS clinics are separated by indication (e.g. DMT / Relapse / Transitioning / Rehabilitation / Continence) please include patients attending any of these. Please record information about the most recent three MRI scans each of the patients has had, regardless of whether they happened before or after this date.

Please EXCLUDE patients without an established diagnosis of MS, patients currently on DMT as part of a clinical trial or research study and patients who have had an MRI during the audit period (last three MRIs) as part of a clinical trial or research study.

The aim of the audit is to collect data from the recent clinic letter(s) and digital PACS system. Hence, year of MS diagnosis and ambulation status are optional fields, for those centres where this information is readily available. If scans are performed >10 years ago or are not available on your local digital system please document ‘Unavailable’ in the ‘Reason for most recent scan’ box and move on to the next patient.

Please also request details of the MRI sequences included in the following protocols from your local radiology department: MS diagnostic, MS monitoring, MS suspected relapse and PML surveillance. Not all centres will break down their protocols into these categories, so please collect all that are pertinent. Please ask them if scans are routinely reported by general radiologists, neuroradiologists or external service providers or a combination. Please provide this information along with your centre name and completed audit data to: linford.fernandes@nhs.net

National data collection to take place between 1^st May 2020 and 12^th June 2020. All those contributing data will be recognised with authorship in any output(s) and will receive a copy of the national dataset.

Objectives and standards

1. Patients on DMTs should have MRI at appropriate intervals to assess their treatment response
   1. Criteria – Patients with MS on DMT should have a monitoring MRI scan every 12 months
      Target – 100%
      Exceptions – Patients who have been stable on DMTs for more than three years Evidence source – MAGNIMS 2015
   2. Criteria – Patients with MS should have an MRI within the first 12 months of commencing a DMT, or switching to a new DMT
      Target – 100%
      Exceptions – None
      Evidence source – MAGNIMS 2015
2. MRI protocols should be relevant to the indication for the imaging in patients with MS.
   1. Criteria – Patients having a diagnostic MRI or to confirm relapse should have a T1 weighted post gadolinium sequence
      Target – 100%
      Exceptions – None
      Evidence source - MAGNIMS 2015
   2. Criteria – MRI spine should not be part of the routine imaging protocol
      Target – 100%
      Exceptions – Diagnostic scans and atypical/unexpected spinal symptoms
      Evidence source – MAGNIMS 2015
   3. Criteria – MRI scans for patients on natalizumab or for PML surveillance should include FLAIR, T2 weighted and DWI sequence
      Target – 100%
      Exceptions – None
      Evidence source – Consortium of MS centres 2018
3. MRI should be used appropriately in disease surveillance and pharmacovigilance for patients with MS on DMTs
   1. Criteria – MRI should be performed at least every 12 months for serum JC virus antibody negative patients on natalizumab
      Target - 100%
      Exceptions – None
      Evidence source – Consortium of MS centres 2018
   2. Criteria – MRI should be performed every 3 months (high index) to 6 months (low index) for serum JC virus antibody positive patients and > 18 months on natalizumab
      Target - 100%
      Exceptions – None
      Evidence source – Consortium of MS centres 2018

References

1. Schmierer K, Campion T, Sinclair A, van Hecke W, Matthews PM, Wattjes MP. Towards a standard MRI protocol for multiple sclerosis across the UK. Br J Radiol 2019; 92: 20180926.
   
2. NICE. Multiple sclerosis in adults: management guidance. (NICE, 2014).
   
3. Rovira, À. et al. MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—establishing disease prognosis and monitoring patients. Nat. Rev. Neurol. 11, 1–12 (2015).
   
4. Consortium of MS centres. Revised Guidelines of the Consortium of MS Centers MRI Protocol for the Diagnosis and Follow-up of MS. (2018)

If interested please contact linford.fernandes@nhs.net for the audit toolkit.