Decision-making in Multiple Sclerosis: The Role of Aversion to Ambiguity for Therapeutic Inertia among Neurologists (DIScUTIR MS)

Gustavo Saposnik, Angel P Sempere, Daniel Prefasi, Daniel Selchen, Christian C Ruff, Jorge Maurino, Philippe N Tobler, Gustavo Saposnik, Angel P Sempere, Daniel Prefasi, Daniel Selchen, Christian C Ruff, Jorge Maurino, Philippe N Tobler

Abstract

Objectives: Limited information is available on physician-related factors influencing therapeutic inertia (TI) in multiple sclerosis (MS). Our aim was to evaluate whether physicians' risk preferences are associated with TI in MS care, by applying concepts from behavioral economics.

Design: In this cross-sectional study, participants answered questions regarding the management of 20 MS case scenarios, completed 3 surveys, and 4 experimental paradigms based on behavioral economics. Surveys and experiments included standardized measures of aversion ambiguity in financial and health domains, physicians' reactions to uncertainty in patient care, and questions related to risk preferences in different domains. The primary outcome was TI when physicians faced a need for escalating therapy based on clinical (new relapse) and magnetic resonance imaging activity while patients were on a disease-modifying agent.

Results: Of 161 neurologists who were invited to participate in the project, 136 cooperated with the study (cooperation rate 84.5%) and 96 completed the survey (response rate: 60%). TI was present in 68.8% of participants. Similar results were observed for definitions of TI based on modified Rio or clinical progression. Aversion to ambiguity was associated with higher prevalence of TI (86.4% with high aversion to ambiguity vs. 63.5% with lower or no aversion to ambiguity; p = 0.042). In multivariate analyses, high aversion to ambiguity was the strongest predictor of TI (OR 7.39; 95%CI 1.40-38.9), followed by low tolerance to uncertainty (OR 3.47; 95%CI 1.18-10.2).

Conclusion: TI is a common phenomenon affecting nearly 7 out of 10 physicians caring for MS patients. Higher prevalence of TI was associated with physician's strong aversion to ambiguity and low tolerance of uncertainty.

Keywords: decision-making; disease-modifying therapy; multiple sclerosis; neuroeconomics; risk aversion.

Figures

Figure 1
Figure 1
Decision scenarios used to measure ambiguity in financial (A) and health (B) domains. Participants were told to imagine two different types or urns. For urn type A, they knew that 50% of the balls were red and the other 50% were blue. For urn type B, they did not know the exact proportion of blue to red balls, with the gray bar representing the unknown proportion of balls. For the financial domain, participants knew that if they drew a blue ball, they would win the full amount of $400. If they drew a red ball, they would win $0. For the health domain, participants decided between two treatments for a patient. With “Treatment A,” the patient had a 50% probability of survival. With “Treatment B,” the exact probability of survival was unknown, with the gray bar representing the unknown probability.
Figure 2
Figure 2
Prevalence of therapeutic inertia (TI) among participants with high ambiguity aversion in the financial domain and low tolerance to uncertainty in patient care. See description in the text for the criteria of TI. *p = 0.042; **p < 0.01.

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