Abstract Details

Title Kaiser Permanente's Rational, Risk-Stratified, Cost-Sensitive Multiple Sclerosis Treatment Algorithm

Topic Practice, Policy, and Ethics

Presentation(s) S22 - Practice, Policy, and Ethics: Improving Patient Care and the Rise of Telemedicine (5:18 PM-5:30 PM)

Poster/Presentation
Number 010

Objective To develop a rational, risk-stratified treatment algorithm to increase utilization of highly effective DMTs (HET) prior to development of irreversible disability and maximize affordability.

Background Highly effective multiple sclerosis (MS) disease-modifying treatments (DMTs) are under-utilized even in patients at high risk of developing disability, in part due to fear of rare but serious risks. Existing treatment guidelines and most insurance coverage policies do not consider a patient’s underlying risk of developing permanent disability.

Design/Methods We developed a risk-stratification schema in KPSC beginning in 2012 to classify patients with relapsing forms of MS as high-, intermediate- or low-risk of disability based on the best available evidence and when evidence was poor or lacking consensus. We pre-specified evidence-based criteria for 1) classifying DMTs as highly or modestly effective (meDMT) and 2) establishing a preferred treatment hierarchy within each class. We reviewed FDA documents and the published literature. Costs of DMTs are incorporated when efficacy and safety profiles are equivalent.

Results

Our treatment algorithm recommends that relapsing MS patients in the high-risk group be on a HET at diagnosis. Patients in the intermediate-risk group who have continued disease activity on one meDMT should be escalated to a HET. Based on more favorable safety profiles, our preferred approach prioritizes use of rituximab and natalizumab among HETs and the lowest priced interferon-betas (IFN-beta) or glatiramer acetate (GLAT) among meDMTs. Patients on non-preferred IFNbeta or GLAT products are converted to the preferred DMT. If the price is significantly higher for the preferred IFN-beta versus GLAT, then the lowest price meDMT is recommended for first-starts with a low threshold for switching.

Conclusions In contrast to most existing coverage policies, our risk-stratified treatment approach does not require patients at high risk of disability to first fail a meDMT before allowing access to HETs. Payers can adapt this treatment algorithm to maximize affordability.

Authors/Disclosures
Annette M. Langer-Gould, MD, PhD (Kaiser Permanente Southern California) PRESENTER	An immediate family member of Dr. Langer-Gould has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Annals of American Thoracic Society. The institution of Dr. Langer-Gould has received research support from PCORI. The institution of an immediate family member of Dr. Langer-Gould has received research support from PCORI, ARQ, NIH. Dr. Langer-Gould has a non-compensated relationship as a Voting Member with ICER CTAF Panel that is relevant to AAN interests or activities.
	No disclosure on file
	No disclosure on file
Brandon E. Beaber, MD (Kaiser Permanente)	No disclosure on file
Sonu M. Brara, MD (Kaiser Permanente)	No disclosure on file
Allen S. Nielsen, MD (Kaiser Permanente-Fontana)	No disclosure on file
Julie DeBacker, MD (Kaiser Permanente)	Dr. DeBacker has nothing to disclose.
Oluwasheyi A. Ayeni, MD (Kaiser Permanente of Georgia)	No disclosure on file

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