Study Probes Effect of Shared Decision-Making on MS Care in The Netherlands

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The Dutch study sought to add to what is known about the cost-effectiveness of shared decision-making in multiple sclerosis.

Researchers recently examined whether shared decision-making for disease modifying therapies (DMTs) could be cost-effective compared with the usual care, given the high rates of discontinuance or nonadherence with such treatments in relapsing-remitting multiple sclerosis (RRMS).

They adapted a state transition model developed by the Institute for Clinical and Economic Review (ICER) to apply to the Netherlands, where 88 per 100,000 individuals are diagnosed with MS, and each year another 5 per 100,000 people will be diagnosed. In the Netherlands, MS care cost about €204.2 million (US$247 million) in 2017, with 46% going to hospitals and specialists and 35% for prescription drug treatment.

Most patients with MS have RRMS; some transition to secondary progressive MS (SPMS), characterized by a shift from relapses and remissions to a gradual continuous worsening of symptoms.

The state transition model evaluates the cost-effectiveness of a range of DMTs for RRMS; the researchers in this study modified the model to a Dutch point of view to assess the cost-effectiveness of implementing shared decision-making regarding DMT choice and estimated the potential societal costs, given that implementing shared decision-making represents an investment that diverts funds away from other health care areas.

However, up to 31% of patients with RRMS discontinue DMTs within the first year, and of the patients who do continue, about 40% are nonadherent. DMTs can reduce the number and severity of relapses as well as forestall disability, but choosing which one to use, or whether to use them at all, can be difficult given different side effects and administration regimens, among other factors.


The researchers said that evidence for shared decision-making, which may decrease such nonadherence and discontinuation rates, in the context of RRMS is limited.

In this study, the simulated population were adults with RRMS without prior use of DMTs, with a mean age of RRMS onset of 37; the majority (71%) were female.

The study examined 3 potential effects of shared decision-making:

  • Changing the initial DMT
  • A decrease in the patient’s discontinuation in using the DMT
  • An increase in adherence to the DMT

The intervention was using shared decision-making, and usual care was one where the provider would largely make the treatment choice for the patient.

The simulation modeled the disease course of RRMS and the risk for progression to SPMS by including 20 health states, defined by the Expanded Disability Status Scale (EDSS), that patients with MS could move through.

Results were analyzed with a 1-way and probabilistic sensitivity analysis of a scenario that combined the 3 effects. Results showed that each effect separately as well as the 3 effects combined resulted in higher quality-adjusted life years (QALYs) and costs due to the increased utilization of DMT. The incremental cost-effectiveness ratio (ICER) was most impacted by a decrease in the discontinuation of DMTs.

The combined scenario resulted in an ICER of €17,875 (US$21,670) per QALY gained, and the ICER was sensitive to changes in several situations.

The accepted cost-effectiveness threshold for diseases categorized as moderately burdensome in the Netherlands is €50,000 (US$60,615).

The ICER fell below that level using the assumption that shared decision-making would reduce discontinuation rates by 50%, increase the proportion of adherent patients by 5%, and lead to a slight increase in starting a DMT as well as use of second-line and orally administered first-line DMTs.

The probability that the intervention would be cost-effective in comparison with usual care was 98.5% for a threshold of €50,000 per QALY.

In addition, 1-way sensitivity analyses showed that the ICER was robust for changes in costs of the intervention but more sensitive to variation in relative risk of progression for each DMD, drug costs, discount rates, or changes in perspectives.


Kremer IEH, Hiligsmann M, Carlson J, et al. Exploring the cost effectiveness of shared decision making for choosing between disease-modifying drugs for relapsing-remitting multiple sclerosis in the Netherlands: A state transition model. Med Decis Making. 2020;40(8):1003-1019. doi: 10.1177/0272989X20961091.