Disease Modifying Therapies: A Comparison of Initiation Timescales Between Patient Location and Medication Type Within the Sheffield MS Service

Introduction: The Sheffield MS team provides a regional service with the provision of 12 NHS England funded disease-modifying therapies (DMTs) through a hub and spoke model. It is not known how long it takes for patients to receive treatment following Bluteq funding approval. Delays can result in patient anxiety and calls to the MS service. By establishing how long it takes for a treatment to commence, we will be able identify areas to improve and provide a better service for patients. Furthermore, by establishing baseline data, we will be better able to repeat the project in the future as new treatments come along. This will show how the treatments impact on the service and help to identify any issues there may be with their provision.

Aims and Objectives:

• Determine how long it takes for patients to receive their first dose of DMT after funding approval.
• Compare the time to first dose between different geographical areas, and different DMTs, both via Homecare supply and hospital administration.
• Identify issues that may result in delays to DMT commencement.

Methods:

Bluteq approval forms from October 2018 to April 2019 were reviewed to identify patients who had started or changed treatment over a six month period. Information was then retrieved from an in-house DMT management system (Infoflex), Pharmacy dispensing records and Homecare delivery company records to establish a timeline from Bluteq approval date to a patient receiving treatment. Data were input and analysed within Microsoft Excel.

Results:

A total of 167 patients were found to have started or changed to a new DMT over the sample period: 83 patients started a homecare-provided treatment (Interferon Beta, Glatiramer Acetate, Dimethyl Fumarate, Teriflunomide, Cladribine); 84 patients started a treatment requiring day case initiation or administration (Fingolimod, Natalizumab, Ocrelizumab, Alemtuzumab). 37% DMTs were a patient’s first treatment.

The median time from Bluteq approval to a patient receiving treatment was 27 (range 9-174) and 39 (range 10-150) days for Homecare and day case treatments respectively. With the exception of teriflunomide, little difference was seen in the provision of DMTs via Homecare. Greater variation was observed with day case treatments. Variation was also seen when comparing different patient areas (Sheffield, Doncaster, Rotherham, Barnsley, North East Derbyshire, North Nottinghamshire, Huddersfield, Out of Area).

Discussion:

Provision of Homecare treatments was typically quicker than those requiring day case admission. With growing concerns over day case unit capacity and the increasing use of infusion therapies, this needs to be addressed. Of the Homecare treatments, teriflunomide took longer to start due to prolonged lymphopenia and thrombocytopenia following treatment with dimethyl fumarate. Natalizumab was the quickest day case-initiated DMT to start – its quick infusion time allows more patients to be treated each day. Alemtuzumab took the longest time to start but requires at least three subsequent day case admissions. Some patients, especially travelling large distances were admitted as an inpatient for treatment.

When reviewing treatment timelines based on patient location, it was found that it took a median of 51 days to receive Homecare treatments if from Doncaster. This is significantly longer than patients in other areas such as Sheffield or Rotherham. Doncaster patients make up 21% of those treated by the Sheffield MS team. Currently, we believe that increasing the number of MS nurses in the Doncaster area would bring the time scale in line with other areas. It may also be beneficial to ensure all team members regardless of location or employer have access to all of the same systems and information.

Recommendations:

• Use this information to develop and improve patient education materials around the process of starting DMTs.
• Encourage staff to fully document issues around delays with DMTs within the Infoflex system.
• Review day case service capacity and explore processes that could improve efficiency and reduce duplication of work, to meet growing demands, e.g. electronic prescribing, non-medical prescribing, systems access, and clarification of roles and responsibilities within the multidisciplinary team.
• Use the findings to assess MS nurse provision between the different areas with the potential to develop business cases for service expansion.
• Disseminate findings to the Homecare team.