Time from MDT to DMT

Introduction

Multiple Sclerosis (MS) is a chronic, inflammatory immunological disease characterised by demyelination of the central nervous system. Epidemiological data suggests that the incidence has increased, however the course of the disease is not as severe due to treatment with Disease Modifying Therapies (DMT’s) (Koch-Henriksen et al. 2021). Early diagnosis and treatment are linked with better outcomes for patients with MS in terms of relapse rate and disease progression (Tobin, 2021).

University Hospital Coventry and Warwickshire is a large NHS trust and sub-regional centre for the diagnosis and treatment of MS. It covers Kettering as a ‘Hub and spoke’ model. The Multidisciplinary Team meeting (MDT) meets twice a month and consists of 3- 4 neurologists and 5 MS nurses. Unfortunately no neuropharmacist or neuroradiologist attends. At present we do not have a DMT co-ordinator, therefore the workload falls on the MS nurses, who also have to manage a busy infusion suite.

The process of commencing patients on DMT is very time consuming for the MS nurse following discussion at MDT. It involves contacting the patient and discussing the outcomes, blood screening, and education, discussion regarding potential risks and side effects of treatment and processing the prescription. Capturing the length of time from discussion at MDT to actual start of DMT can be a useful tool in assessing how efficient the service is.

Objective

The aim of this audit was to establish how long it takes on average to commence patients on DMT following discussion at MDT. Also to evaluate if the increased pressure on the MS service over the last 2 years had an impact on the time it took to commence patients on treatment. Delays to commencing DMT can potentially cause harm to patients. Although there is no specific timeframe, NICE guidelines (2014) suggest treatment should start as early as possible.

The MS service in UHCW has been under extra pressure due to the impact of Covid and staff redeployment, also 2 members of the team had to ‘shield’. However, ‘Time is Brain’ and delays on commencing patients on DMT can ultimately impact on the long term outcome of their disease.

Methodology

A database ‘Dendrite’ was established in mid-2019 at UHCW to replace paper notes and improve MS patient records. At present there are 2460 patient records on the database, 70 % are female, 30 % male. 46% of patients are RRMS and 653 patients are on DMT. However without a dedicated systems administrator to maintain accurate records on the database, this remains a huge challenge for the team in the future. Interestingly there was a 252% rise in patients diagnosed with MS between 2000-2004, which has a significant impact on the service going forward if these trends continue.

Retrospective MDT minutes from monthly meetings were examined from the years 2018-2021. Similar months were chosen (April/May) of each year. The database was then searched to establish the actual start date of treatment for all of the 29 patients discussed at MDT. One significant observation was that accurate dates were not always recorded on the database, and this hindered the audit process. In the cases where start dates had not been entered on the database, clinic letters were retrieved and DMT start dates obtained. An average time in weeks could then be calculated from discussion at MDT to commencing treatment.

Results & Recommendations

The results show that despite the immense challenges on the MS service, the timeframe for commencing patients on DMT actually improved since 2018. Given the challenges of Covid and the implications of staff shortages, this is encouraging. Changes to the MDT process had been introduced. The process of contacting the patient regarding the outcome began immediately after MDT. Whereby, historically a letter from the consultant neurologist instructing the MDT decision was awaited prior to contacting the patient. This has improved the overall process.

From examining the data, delays in starting DMT were due to various reasons. One significant factor was non-immunity to MMR and VZV antibodies for patients commencing higher efficacy DMT. Therefore patients have to be immunised and have antibodies re-checked 4-6 weeks post vaccine, which can cause significant delays. Other recent delays were related to Covid vaccine, and commencing Ocrelizumab. Other issues were related to patients using stock of old DMT and washout periods. Additionally if patients were ‘out of area’, they require referral into the MS service at UHCW, which also delayed the process due to lack of clinic slots.

More recently delays in homecare companies delivering medications have been an issue, and a significant factor in delaying start times of DMT. This may need to be audited in the future. We currently post out DMT booklets following MDT, which is costly and time consuming. Moving forward electronic forms of DMT booklets would save money, time and have less impact on the environment.

Conclusions

In conclusion, despite the immense challenges to the MS service in UHCW. The results are surprisingly encouraging, in regard to the timeframe from MDT to DMT. Reasons to delays in commencing treatment are wide ranging. However, a significant issue that was identified was non-immunity to MMR and VZV. Therefore it may be beneficial to screen immunity as a baseline for patients who we suspect may need higher efficacy treatment, so vaccination can be arranged promptly and prevent delays in commencing treatment. Furthermore, accurate data entry on the database is essential, including DMT start dates in order to ease the process of future audits. A DMT co-ordinator would hugely benefit the MS team at UHCW and ease the workload on the MS nurses. As more DMT’s are prescribed for all types of MS, the pressure will only increase on the MS service in the future.

References

• Koch-henriksen, N., Magyari, M. (2021) ‘Apparent changes in the epidemiology and severity of multiple sclerosis’. Nat rev Neurol 17, 676-688.
• National Institute for Health and Care excellence (2014) Multiple Sclerosis in adults: Management (CG186) Available at https://www.nice.org.uk/guidance/cg186.
• Tobin, O, W. (2021) ‘Early diagnosis and treatment are associated with improved outcomes in patients with multiple sclerosis.’ Neurology October 2021, 97 (17) 799-800.