How to optimize the multi-disciplinary approach?

Professor Gavin Giovannoni

Blizard Institute, Barts and The London School of Medicine

and Dentistry

Disclosures

Professor Giovannoni has received personal compensation for

participating on Advisory Boards in relation to clinical trial design,

trial steering committees and data and safety monitoring committees

from: Abbvie, Bayer-Schering Healthcare, Biogen-Idec, Canbex,

Eisai, Elan, Fiveprime, Genzyme, Genentech, GSK, GW Pharma,

Ironwood, Merck-Serono, Novartis, Pfizer, Roche, Sanofi-Aventis,

Synthon BV, Teva, UCB Pharma and Vertex Pharmaceuticals.

Regarding www.ms-res.org survey results in this presentation:

please note that no personal identifiers were collected as part of

these surveys and that by completing the surveys participants

consented for their anonymous data to be analysed and presented

by Professor Giovannoni.

Calls to action

1. Develop new tools to better capture the

total clinical burden of MS (Call 4).

2. Stimulate the implementation of

specialised care centres and support

people with MS remaining (physically)

active and at work (Call 9).

What is the unmet need and

from who’s perspective?

UNMET NEEDSHCP Perspective

UNMET NEEDSPatient Perspective

Epstein Bar Virus

Genetics

Vitamin D

Smoking

Risks

Adverse events

DifferentialDiagnosis

MRI

EvokedPotentials

Lumbar puncture

BloodTests

DiagnosticCriteria

Cognition

Depression

Fatigue

Bladder

Bowel

Sexual dysfunction Tremor

PainSwallowing

SpasticityFalls

Balance problems Insomnia

Restless legsFertility

Clinical trials

Gait

Pressuresores

Oscillopsia

Emotionallability

Seizures

Gastrostomy

Rehab

Suprapubiccatheter Intrathecal

baclofen

Physio-therapy

Speech therapy

OccupationalTherapy

Functional neurosurgery

Colostomy

Tendonotomy

Studying

EmploymentRelationships

Travel

Vaccination

Anxiety

Driving

Nurse specialists

Family counselling

Relapses

1st line

2nd line

Maintenance Escalation Induction

Monitoring

Disease-free

Disease progression

DMTs

Side Effects

Advanced Directive

Exercise

Diet

AlternativeMedicine

PregnancyBreastFeeding

Research

Insurance

Visual loss

PalliativeCare

Assistedsuicide

Socialservices

Legalaid

Genetic counselling

Prevention

Diagnosis

DMTSymptomatic

Therapist

Terminal

CounsellingThe MS journey – www.ms-res.org

Intrathecalphenol

Fractures

Movement disorders

Osteopaenia

Brain atrophy

Hearing loss

Tinnitus

Photophobia

Hiccoughs

DVLA

Neuroprotection

Psychosis

Depersonaliation

BrainHealth

CognitiveReserve

Sudden death

Suicide

OCD

Narcolepsy

ApnoeaCarers

Respite

Hospice

Respite

Dignitas

Advanced Directive

Rhiztomy

Rhiztomy

Wheelchair

Walking aids

Blood/Organdonation

Brain donation

Exercise therapy

NABs

Autoimmunity

Infections

Outcome measures

WebResources

Pathogenesis

Doublevision

What isMS?

NEDA

T2TOCT

Neurofilaments

JCV statusPharma

Anaesthesia

The unmet need (50% / 80%)

0

10

20

30

40

50

60

70

80

90

Work Capacity by Disability Level

0.0/1.0 2.0 3.0 4.0 5.0 6.0 6.5 7.0 8.0/9.0

EDSS Score

Pro

po

rtio

n o

f p

ati

en

ts ≤

65 y

ears

old

wo

rkin

g (

%)

The proportion of patients employed or on long-term sick leave is calculated as a percentage of patients aged 65 or younger.

1. Kobelt G et al. J Neurol Neurosurg Psychiatry 2006;77:918-26;

2. Pfleger CC et al. Mult Scler 2010;16:121-6.

Spain

Sweden

Switzerland

United Kingdom

Netherlands

Italy

Germany

Belgium

Austria

~10 yrs2

80%50%

Multi-disciplinary care teams

MDT: multi-disciplinary care team; OT: occupational therapist

MS centre of excellence (same campus)

Minimal MDT (same building, working closely together)

Neurologist MS nursePsychologist / rehabilitation

physician

MS network (regional)

Rehabilitation disciplines (physio, OT,

neuro-psych, social worker,

speech…

Other medical specialists

(ophthalmologist, urologist,

psychiatrist, radiologist …)

MDCT - Definition (1)

A multidisciplinary care team can be defined

as a partnership among health care workers of

different disciplines inside and outside the health

sector and the community with the goal of

providing quality continuous, comprehensive

and efficient health services.

www.iapac.org

GP

Neuro-logist

MSer

Nurse Specialist

Neuro-rehab

Neuro-logist

GP

MSer

Nurse Specialist

Neuro-rehab

Nurse Specialist

GP

Neuro-logist

MSer

Neuro-rehab

MSer

GPNeuro-logist

Nurse Specialist

Neuro-rehab

Continence Advisor

Ophthal-mology

PhysioOT

Speech

Psychology

Psychiatry

Podiatry

Neuro-surgery

Concordance modelCompliance model

Prescriber decides

diagnosis and treatment

Prescriber’s task is to

explain and instruct

Patient’s task is to

comprehend

Successful outcome is

compliance

Prescriber and patient

negotiate diagnosis and

treatment

Prescriber elicits, explains,

persuades and

accommodates

Patient explains, considers

and accommodates

Successful outcome is a

negotiated agreement

Moving from compliance to concordance

requires a culture change

Source: From Compliance to Concordance, 1997

ICP - Definition (2)

An integrated care pathway (ICP) is a

multidisciplinary outline of anticipated care, placed

in an appropriate timeframe, to help a patient with

a specific condition or set of symptoms move

progressively through a clinical experience to

positive outcomes

www.medicine.ox.ac.uk/bandolier/booth/glossary/icp.html

ICP

https://www.rcplondon.ac.uk/sites/default/files/ms_audit_executive_summary_2011_1.pdf

Uberization of Healthcare

CD - Definition (3)

Creative destruction refers to the incessant

product and process innovation mechanism by

which new production units replace outdated ones.

It was coined by Joseph Schumpeter (1942), who

considered it 'the essential fact about capitalism'.

www.economics.mit.edu/files/1785

eHealth

Monitoring & managing your

own disease

1. Consumers, for the most part, just weren't interested or didn't even know what a personal e-health record is.

2. Consumers who are aware of PHRs tend to use physician, hospital, and even health-plan portals to keep track of their records.

3. Lack of provider relationships and other data sources.

4. Google lacked other communication and convenience features that patients look for when dealing with their health information electronically.

5. Privacy and security concerns by consumers, whether warranted or not.

Change

Evidence-based education

1. Adoption of concordance model (multi-disciplinary partnership) 2. Recognise cycles of innovation

a. Evolution vs. revolutionb. Creative destruction (technology-driven)

3. Education, education, education (MSers and HCPs)4. Empowerment; HCPs accountable to MSers5. Mechanism of sharing of best practice6. Social Sciences (adoption vs. non-adoption)

a. Diffusion of innovations b. Nudge theoryc. Behavioural change

Calls to action

1. Develop new tools to better capture the

total clinical burden of MS (Call 4).

2. Stimulate the implementation of

specialised care centres and support

people with MS remaining (physically)

active and at work (Call 9).

Calls to action

1. Develop new tools to better capture the total clinical burden of MS (Call 4).

2. Stimulate the implementation of a set of evidence-based standards of care, with audit tools, and the means and incentivesto support people with MS remaining physically and mentally active and at work (Call 9).

Conclusions (1)

Rethink the relationship of patient/MSer-HCP

relationship

Rethink the architecture of the health service

Concordance model: MSer and HCP are partners

Define healthcare objectives

• Sickness behaviour vs. health/wellness behaviour

Adopt new technologies

• eMonitoring and eHealth

• Hurdles to adoption are not insurmountable

• Privacy, data protection and medico-legal issues

Conclusions (2)

Multidisciplinary approach is here to stay and should be

the norm

Set the agenda and/or framework

• Evidence-based

• Guidelines

• Quality metrics

• Regular audit and cycles of improvement

• Education

o HCPs

o MSers

o Etc.