Real-Life Outcome in Multiple Sclerosis in the Czech Republic

BACKGROUND: Cohort studies and registries provide opportunities to estimate long-term outcome in multiple sclerosis. OBJECTIVES: To describe changes in disability (EDSS), relapse activity, and health care consumption over the period 2008-2015 by combining two Czech cost-of-illness studies with disease data from the MS Center in Prague. METHODS: The combined dataset included 426 patients with a mean observation time of 8.3 years. A Cox proportional hazards model with time-varying covariates for treatment, disease course, and EDSS was applied to estimate the effect of treatment on the risk of progression to EDSS 4 and the risk of relapses. The use of health care resources (hospitalization, consultation, and tests) was compared between the two cross-sectional studies. RESULTS: Total health care costs appeared stable between 2008 and 2015, despite more intense use of disease-modifying treatments in 2015 (52% of patients versus 31% in 2008). 39% of patients starting treatment at EDSS 0-3 in 2008 progressed to EDSS 4 or higher by 2015, while 65% of patients starting at EDSS 0-2 remained stable. The number of relapses was associated with a higher risk of progression. In a marginal structural Cox model of the relapse risk, treatment with natalizumab or fingolimod was associated with a lower risk of relapse (hazard ratio 0.68, p<0.01). Treatment with natalizumab or fingolimod was associated with a lower risk of progression to EDSS 4. CONCLUSION: Our results link relapses to progression and indicate that the newer treatments have a better effectiveness, despite difficulties caused by small a sample size, administrative rules guiding treatment, and absence of a random comparator group.