Does Your Multiple Sclerosis Specialist Follow the Herd?

                                                                  

People diagnosed with multiple sclerosis (MS) and their neurologists must make many decisions when it comes to treating the disease. With FDA-approved disease-modifying therapies, it can be challenging to know which one to use, if any.

How do doctors and patients choose? To make an informed decision, neurologists are expected to follow clinical practice guidelines that frequently summarize the available medical evidence. Meanwhile, patients are expected to do their own research and consider lifestyle factors and personal preference, as well as doctor recommendations.

It’s clearly unwise for neurologists to follow outdated clinical guidelines; consider that when the American Academy of Neurology (AAN) published its guidelines in 2002, only four treatment options were available. A less obvious concern is when neurologists ignore current clinical guidelines and instead follow the recommendations of other neurologists they know or experts in the field, a behavior called “herding.”

Herding can be detrimental to patient care, suggests a study published in January 2017 in the journal Patient Preference and Adherence.

Herding is a phenomenon in which individuals follow the behavior of others rather than making a decision independently. Herding occurs in MS care when one neurologist follows the therapeutic recommendation of a colleague even when this advice is not supported by clinical guidelines.

To measure the potential of herding behavior in MS treatment, researchers in Spain conducted a study among neurologists with expertise in MS patient care. Participants answered questions regarding 20 case scenarios commonly encountered in clinical practice and completed three surveys and four experimental paradigms based on behavioral economics.

One case scenario involved a 40-year-old woman who had been stable for three years on subcutaneous interferon therapy before a minor relapse. Magnetic resonance imaging (MRI) revealed no new lesions, and the results of her neurological examination and disability scores were unchanged. The patient was advised by an MS neurologist — a colleague of her regular doctor — to switch from interferon to fingolimod, a recommendation that went against current best-practice guidelines.

The neurologists participating in the study were asked what treatment they would recommend for this patient after learning of the colleague’s suggestion. Those who decided to go with the colleague’s choice were considered to be herding.

Of the 96 neurologists in the study, herding behavior was present in 75 (78.1 percent overall). General neurologists showed greater herding behavior than MS experts — 82.8 percent versus 68.8 percent, respectively. The physicians who saw greater numbers of MS patients each per week were more likely to herd. Physician age, gender, years of practice, setting of practice, and risk preferences were not associated with herding.

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