Role of disease-modifying therapies on employment among veterans with multiple sclerosis
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Role of disease-modifying therapies on employment among veterans with multiple sclerosis

Can adherence to prescribed treatment for multiple sclerosis (MS) improve employment rates among veterans with the disease?

Multiple sclerosis (MS) mainly affects young adults in the prime of their lives, with the highest incidence occurring between the ages of 20 and 40. At present, there are no cures for MS disease. Hence, treatments are designed to modify the disease’s progression or alleviate symptoms. These treatments are called disease-modifying therapies (DMTs).

Figure 1. An overview of multiple sclerosis
Credit Source: Ravi Singh K

Link between emplyement and MS

Employment provides financial security, a better quality of life, and social contacts. Additionally, it establishes an individual’s identity and promotes self-esteem. Loss or underemployment is associated with financial instability, social isolation, and mental health implications for patients and their families, leading to a significant decline in patients’ quality of life.

Employment rates for people with MS are less than 50% due to several patient-related issues such as age, gender, and level of education. Additionally, disease-related symptoms like visual impairment, depression, cognitive issues, fatigue, and motor weakness also play a role in the lack of employment opportunities. Furthermore, workplace barriers, including employers’ attitudes, can also limit the employment of individuals living with MS.

What are adherence rates for DMTs?

Abiding by the prescribed dose, frequency, and timing of medication, known as “adherence,” is crucial in managing the disease effectively. Since the disease is chronic, it is important to maintain consistent adherence to medication over an extended period. Studies have shown that adherence rates for chronic medical conditions such as hypertension and diabetes are less than 50%. Similarly, adherence rates for injectable DMTs in patients with MS are also less than 50%. Non-adherence to DMTs has been linked to worsening morbidity, increased healthcare costs and mortality. Furthermore, nonadherence negatively affects a person’s functioning by increasing disability and hindering their ability to retain employment. 

Most studies conducted on adherence in MS have been done in the context of clinical trials. Still, the follow-up period is usually only 12–24 months, which is insufficient to understand the disease’s long-term impact. MS is a progressive disease which deteriorates neurological function over time. Thus, it is important to have long-term studies to understand its impact. Furthermore, many studies are retrospective, which limits their applicability to real-world clinical practice.

Our research on MS and DMTs

We conducted a study to examine the impact of adherence to DMTs on employment rates among veterans with MS. Adherence levels were determined through face-to-face follow-up visits and classified as non-adherence, good adherence, or poor adherence. Non-adherence was defined as veterans who initially took DMTs but then stopped taking them, or refused to take them from the beginning due to adverse effects, lack of perceived effectiveness, or perceived stability or progression of the disease. 

Good adherence was defined as veterans who took the prescribed DMTs regularly. Poor adherence was defined as veterans who took the prescribed DMTs infrequently, regularly missing two or more doses in 4 weeks. This clinical information was verified using medication possession ratios (MPR) calculated from pharmacy refill data in the veterans’ electronic medical records. An MPR cut score of <0.8 was considered as non-adherence, 0.8-0.9 as poor adherence, and 1.0 as good adherence

In our study, 142 veterans with MS who had regularly visited the MS clinic over 20 years were included. The majority of the veterans were white men (76%), aged 30 to 65, with a disease duration of approximately 20 years. They were diagnosed with relapsing (n=65, 46%), progressive (n=61, 43%), and other types of MS for at least 3 years. Out of these, 47 MS patients (33.1%) were non-adherent to any disease-modifying therapy (DMT) medication, while 88 MS patients (62.0%) demonstrated good adherence and 7 (4.9%) showed poor adherence. 

Key findings of our study!

Our study found that 33.1% of veterans did not adhere to their DMT medication due to a variety of reasons. These reasons included the perception that the medication was not effectively treating the disease, experiencing adverse effects such as injection site reactions and depression, and discomfort with the prolonged use of the medication. Out of the veterans who adhered to their prescribed DMT regimen, 7.4% (7/95) had poor adherence due to forgetfulness or depression.

Patients in the good-adherence group stayed in paid employment 42.0% of the time compared to 23.4% in the non-adherent group. This was after controlling for potential co-founders such as age, level of education, duration of the disease, and MS-related disabilities. Thus, when compared to non- or poorly adherent patients, veterans who followed their DMTs were 2.4 times more likely to be in paid employment. We got an adherence rate of over 60% by informing and encouraging the patients about the benefits of adhering to their prescribed DMTs. Thus, the study tells us that physicians taking care of patients with MS should encourage their MS patients to adhere to their DMTs as a motivating factor for being in and staying in paid employment.

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Journal reference

Rabadi, M. H., Just, K., & Xu, C. (2022). Impact of adherence to disease-modifying therapies on employment among veterans with multiple sclerosis. Disability and Rehabilitation44(16), 4415-4420. https://doi.org/10.1080/09638288.2021.1907621

Dr. Meheroz Hoshang Rabadi is a Clinical Professor and Staff Neurologist at the Oklahoma University Medical Center and Oklahoma City VA Medical Center. With over 40 years of experience as a physician, he holds an MD degree from Dow Medical College (Karachi University) and is Board Certified in Psychiatry and Neurology (ABPN). He is also a Fellow of the American Academy of Neurology (FAAN) and American Neurological Association (FANA). Dr. Rabadi re-organized the Spinal Cord Injury Program at OKC VAMC in 2007, which now includes Spinal Cord Injury/Diseases (SCI/D), Multiple Sclerosis (MS), and Amyotrophic Lateral Sclerosis (ALS).