Article Text

Original research
Ethnicity and deprivation negatively impact the access to disease-modifying therapy for relapsing-remitting multiple sclerosis: a retrospective, single-centre study
  1. Joyutpal Das1,2,
  2. Gagana Mallawaarachchi3,
  3. Jack Grimshaw3,
  4. Thomas Jackson3,
  5. Paul Talbot4,
  6. Nazar Sharaf4,
  7. Thaleia Kalatha4,
  8. Lindsay Lord4,
  9. Adrian Pace4,5,
  10. Tatiana Mihalova4,6,
  11. Calvin Heal7,
  12. David Rog4
  1. 1Cardiovascular Department, The University of Manchester, Manchester, UK
  2. 2Neuroscience Department, Salford Royal Hospital Manchester Centre for Clinical Neurosciences, Salford, UK
  3. 3The University of Manchester, Manchester, UK
  4. 4Salford Royal Hospital Manchester Centre for Clinical Neurosciences, Salford, UK
  5. 5Gozo General Hospital, Victoria, Malta
  6. 6Penta Hospitals, Bratislava, Poland
  7. 7Centre for Biostatistics, University of Manchester, Manchester, UK
  1. Correspondence to Dr Joyutpal Das, Cardiovascular Department, The University of Manchester, Manchester, M13 9PL, UK; joyutpal.das{at}postgrad.manchester.ac.uk

Abstract

Background A growing body of evidence suggests inequitable access to disease-modifying therapies (DMTs) for multiple sclerosis (MS) in publicly funded healthcare systems. This retrospective study examined the impact of ethnicity and deprivation on the access to DMTs.

Methods All adults diagnosed with relapsing-remitting MS between 2010 and 2020 were included. The impact of ethnicity and deprivation on being offered and starting any DMTs and high-efficacy DMTs were measured using binary, multinomial logistic and Cox regression models. These analyses were adjusted for sex, age at diagnosis and year of diagnosis.

Results 164/1648 people with MS (PwMS) were from non-white ethnicities. 461/1648 who were living in the most deprived areas, were less likely to be offered DMTs, with an OR of 0.66 (95% CI 0.47 to 0.93), less likely to start high-efficacy DMTs with an OR of 0.67 (95% CI 0.48 to 0.93) and more likely to experience a delay in starting high-efficacy DMTs with an HR of 0.76 (95% CI 0.63 to 0.92), when also adjusted for ethnicity. Although the offer of DMTs did not depend on ethnicity, PwMS from non-white ethnicities were more likely to decline DMTs, less likely to start any DMTs and high-efficacy DMTs with ORs of 0.60 (95% CI 0.39 to 0.93) and 0.61 (95% CI 0.38 to 0.98), respectively, and more likely to experience a delay in starting DMTs with an HR of 0.79 (95% CI 0.66 to 0.95), when also adjusted for deprivation.

Conclusions In a publicly funded healthcare system, the access to DMTs varied depending on ethnicities and levels of deprivation.

  • MULTIPLE SCLEROSIS
  • HEALTH POLICY & PRACTICE

Data availability statement

No data are available.

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Disease-modifying therapies (DMTs) for multiple sclerosis (MS) are expensive.

  • In privately funded healthcare systems, these DMTs are unaffordable to many people with MS (PwMS).

  • The access to these DMTs is also not equitable in publicly funded healthcare systems.

WHAT THIS STUDY ADDS

  • PwMS from non-white ethnic backgrounds were more likely to decline DMTs for MS, although they did not require to pay for their treatments including DMTs.

  • PwMS from non-white ethnic backgrounds were less likely start DMTs for MS than others.

  • PwMS who were living in the most deprived areas were less likely to be offered DMTs for MS than others.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • To design an equitable service, special attention should be paid to those who are from non-white ethnicities or living in deprived areas.

Introduction

Health inequality exists in both privately and publicly funded healthcare systems. Disease-modifying therapies (DMTs) for multiple sclerosis (MS) are expensive and one in five people with MS (PwMS) is unable to afford appropriate DMTs in privately funded healthcare systems.1–8 There is a growing body of evidence suggesting inequity in accessing DMTs for MS in the UK National Health Service (NHS), a publicly funded healthcare system, where PwMS do not pay for their DMTs or other MS care. A number of socioeconomic factors have been associated with inequity in accessing DMTs in publicly funded healthcare systems. University education has been reported to facilitate access to DMTs in the UK and a similar trend has also been observed in Norway, where MS care costs are also subsidised by the government.9 10 Recent studies suggested that PwMS from the most deprived areas in the UK were less likely to receive DMTs than others.7 8 It has previously been reported that PwMS from non-white ethnicities were more likely to decline DMTs than those from White ethnicities.11 Ethnic minorities more commonly live in deprived areas across the UK and ethnic disparity in healthcare access has been reported in the UK, but the exact impact of ethnicity on the access to DMTs for MS remains unknown.12–16 Our study aimed to disaggregate the effect of ethnicity and deprivation on the initial offer, subsequent starting and, in particular, starting of high-efficacy DMTs in PwMS. Additionally, the impact of ethnicity and deprivation on the time to start DMTs was examined.

Methods

Study population, data collection and study criteria

Manchester Centre for Clinical Neurosciences (MCCN) is the sole provider of neurological care for about 2.8 million people in the Greater Manchester and East Cheshire areas in the northwest of England. MCCN is organised as the hub, at Salford Royal Hospital, where the MS DMT assessment and treatment clinics are located, and also 10 spoke (peripheral) hospitals, which conduct general neurology and MS specialist nurse clinics, from where PwMS are referred to the hub for tertiary MS care. Electronic medical records of their neurology care from all peripheral hospitals are recorded centrally at MCCN. The MS database was created at the end of 2014 by amalgamating all the known PwMS in MCCN, regardless of whether they were cared at the hub or at any other peripheral hospitals, and subsequently, all newly diagnosed PwMS were included in this regional database prospectivity.

In this retrospective study, we reviewed the electronic medical records of all adults who were diagnosed with MS between 2010 and 2020 in the MCNN regional service and gathered demographic, socioeconomic and clinical data. DMTs for MS were primarily licensed to treat relapsing-remitting MS in England over this study period. In this study, therefore, only those PwMS who were newly diagnosed with relapsing-remitting MS between 2010 and 2020 at the MCCN were included and those diagnosed elsewhere or without the postcode of residence at the time of diagnosis or ethnicity data were excluded.

Ethnicity and deprivation

The study population was divided into two ethnic groups: white and non-white. People of mixed ethnicities were included in the non-white ethnicity group. The UK Office for National Statistics measures relative deprivation in England by using the Index of Multiple Deprivation (IMD), which comprises seven domains of deprivation including (1) income, (2) employment, (3) education, skills and training, (4) health deprivation and disability, (5) crime, (6) barriers to housing and services and (7) living environment.17 In this study, 2019 English IMD quintiles, derived from the participant’s postcode of residence at the time of MS diagnosis, were used to measure deprivation; Q1 being the most deprived and Q5 the least deprived.17 Access to DMTs was previously reported to be affected at extremes of the IMD scale, and therefore, IMD quintiles were also categorised into the most deprived (Q1) and others (Q2–5) as well as the least deprived (Q5) and others (Q1–4).7

Measuring equity of access to MS DMTs

To assess equity of access to DMTs, we examined whether ethnicity and deprivation had any impact on the initial offer and subsequently starting of DMTs. It was regarded as an ‘offer of DMTs’ if PwMS were offered DMTs by the MS specialists or were referred to DMT clinics for an assessment of eligibility to start DMTs according to the contemporary version of the national MS DMT guidelines.

In addition, we examined the equity of access to high-efficacy DMTs. DMTs were classed into moderate and high efficacies.18 Beta interferons, glatiramer acetate, dimethyl fumarate and teriflunomide were classed as moderate efficacy and all other DMTs such as alemtuzumab, cladribine, fingolimod, natalizumab and ocrelizumab were classed as high-efficacy DMTs.18 Some PwMS may start on moderate efficacy DMTs, before switching to high-efficacy DMTs, due to ongoing disease activity on moderate efficacy DMTs. On the other hand, those who have aggressive inflammatory disease at the time of diagnosis, are likely to start on high-efficacy DMTs. In order to assess for the access to high-efficacy DMTs, those who received both moderate and high-efficacy DMTs, were only included once in the analysis as being in the high-efficacy DMTs group.

Finally, we examined whether ethnicity or deprivation resulted in a delay to start DMTs. Time to start a DMT was measured by calculating the time from MS diagnosis to starting the first DMT regardless of its efficacy whereas the time to start a high-efficacy DMT was measured by calculating the time from MS diagnosis to starting the first high-efficacy DMT.

Statistical analysis

Methods of statistical analyses that were used in this study had previously been described.10 The univariate characteristics of the demographic and clinical features were described using mean with SD and median with 95% CI. Student’s t-test and Mann-Whitney U test were used to measure the statistical significance of means and medians, respectively, whereas χ2 test was used to examine the statistical significance of categorical variables.

Binary (0=did not receive any DMT (reference) and 1=received DMTs) and multinomial logistic regressions (0=did not receive any DMT (reference), 1=received moderate-efficacy DMTs and 2=received high-efficacy DMTs) were used to estimate OR with 95% CI to quantify the association of ethnicity and deprivation with the likelihood of being offered, starting any DMTs and starting a high-efficacy DMT. These statistical models were adjusted for sex, age at diagnosis and year of diagnosis. These models were adjusted for year of diagnosis, as various DMTs were introduced into clinical practice at different time points during the aforementioned study period. These models were adjusted for year of diagnosis rather than year of starting DMTs, as all participants did not start DMTs and therefore the entire study population could not be stratified using the date of starting DMTs. Age at diagnosis and year of diagnosis were introduced to the above statistical models as continuous variables, whereas sex, ethnicity and deprivation were included as categorical variables. The Nagelkerke R2 was used to estimate the amount of variation in accessing DMTs that could be explained by these models.

The Kaplan-Meier (KM) survival curve was used to demonstrate time to start DMTs or high-efficacy DMTs. Log rank (Mantel-Cox test) was used to compare the survival distributions of KM curves. To adjust for above covariates, a Cox proportional hazards regression model was used. For all statistical models, data were censored on 31 December 2021.

As MS may prevent the completion of a person’s education, which subsequently could result in deprivation, the analysis to assess the impact of deprivation was adjusted for reverse causality, by performing a sensitivity analysis, only including those who were diagnosed with MS at the age of ≥30 years, therefore, allowing completion of their education before their diagnosis of MS. People from non-white ethnicities are more likely to live in deprived areas.16 Hence, to understand the interaction between ethnicity and deprivation, another sensitivity analysis was undertaken to only include PwMS from white ethnic backgrounds. Finally, we also perform sensitivity analyses by changing the year of diagnosis from a continuous variable to a categorical variable (≤ 2015 and >2015).

IBM SPSS Statistics V.29.0.0.0 software package was used for all statical analyses, except figure 1 which was created using Microsoft Excel and online supplemental figures created using R V.4.2.1 software package.

Supplemental material

Figure 1

Participants from (A) white (N=1484) and (B) non-white (N=164) ethnic backgrounds, who were offered and started DMTs to show the trend of DMT usage between these two ethnic groups over the study period. If a total number of PwMS from an ethnic group diagnosed in a single year were N, and a total number of these N PwMS who were offered DMTs by the end of the study period were n, black bars represented percentages of those who were offered DMTs by the end of study period, Embedded Image. If a total number of these N PwMS who were started DMTs by the end of study period were m, white bars represented percentages of those who were started DMTs by the end of study period, Embedded Image. DMTs, disease-modifying therapies; PwMS, people with multiple sclerosis.

Results

Demographic and clinical characteristics

A total of 2004 people were diagnosed with MS between 2010 and 2020 at the MCCN. Ethnicity and postcode at diagnosis were not available for 25/2004 (1.2%) and 3/2004 (0.1%) participants, respectively. 1648/1976 (83%) participants had relapsing-remitting MS, and therefore, fulfilled all the inclusion and exclusion criteria. 461/1648 (28%) participants were living in the most deprived areas (Q1). 1484/1648 (90%) participants were from white ethnic backgrounds. Among PwMS from non-white ethnicities, 95/164 (58%) were from Asian ethnic backgrounds, 29/164 (18%) were from black ethnicities and the remaining 40/164 (24%) were from various other ethnicities including mixed ethnicities. PwMS from the non-white ethnic group were diagnosed at a significantly younger age, on average some 6 years, and lived in relatively deprived areas than those from white ethnic backgrounds (table 1). There was no significant difference in the male to female ratio between these two ethnic groups (table 1).

Table 1

Demographic characteristics of the study population (N=1648)

DMT usage increased between 2010 and 2020

Of those PwMS who started DMTs, 87.1% (95% CI 85.2% to 88.9%) started within 2 years of diagnosis. Overall, there was an increase in the use of DMTs between 2010 and 2020 (figure 1A,B). Although the number of individuals diagnosed with MS each year remained at a similar level throughout this study period, the proportion of PwMS that were offered and subsequently treated with DMTs gradually increased suggesting an upward trend of DMT usage in both ethnic groups over this study period.

Deprivation, but not ethnicity had an impact on the offer of DMTs

The likelihood of DMTs being offered did not depend on ethnicities after adjusting for sex, age at diagnosis, year of diagnosis and deprivation (table 2). However, PwMS living in the most deprived areas (Q1) were less likely to be offered DMTs than others (Q2–5) with an OR of 0.66 (95% CI 0.47 to 0.93) when adjusted for sex, age at diagnosis, year of diagnosis (as a continuous or a categorical variable) and ethnicity. On the other hand, living in the least deprived areas (Q5) did not increase the likelihood of DMTs being offered compared with others (Q1–4) (table 2 and online supplemental tables 1 and 2). These findings remained unchanged when corrected for reverse causality or when a sensitivity analysis was performed, including only those PwMS who were from white ethnic backgrounds (online supplemental table 3). Those who were male, younger age at diagnosis and recently diagnosed were more frequently offered DMTs (table 2). The Nagelkerke R2 value of the model explained 25% variation in the offer of DMTs (table 2).

Table 2

Impact of ethnicity and deprivation on being offered or starting DMTs

PwMS from non-white ethnic backgrounds were less likely to start DMTs regardless of their efficacies

Although people from both ethnic groups were equally likely to be offered DMTs, those from non-white ethnic backgrounds were less likely to start DMTs with an OR of 0.60 (95% CI 0.39 to 0.93) and also less likely to start both moderate and high-efficacy DMTs with ORs of 0.59 ((95% CI 0.37 to 0.93) and 0.61 ((95% CI 0.38 to 0.98) respectively, after adjusting for sex, age at diagnosis, year of diagnosis (as a continuous or a categorical variable) and deprivation (table 2 and online supplemental table 1). Nagelkerke R2 values explained a 14% variation in starting any DMTs.

PwMS living in the most deprived areas were less likely to start high-efficacy DMTs

Although PwMS from the most deprived areas (Q1) were less likely to be offered DMTs, deprivation had no impact on starting a DMT. We then examined whether deprivation had any impact on the access to high-efficacy DMTs. PwMS living in the most deprived areas (Q1) were less likely to start high-efficacy DMTs with an OR of 0.67 (95% CI 0.48 to 0.93) compared with others (Q2–5) when adjusted for sex, age at diagnosis, year of diagnosis (as a continuous or a categorical variable) and ethnicity (table 2). Living in the least deprived area (Q5) was not associated with increased likelihood of receiving DMTs regardless of their efficacies (online supplemental table 2). The impact of deprivation on starting DMTs remained unchanged when corrected for reverse causality or when a sensitivity analysis was performed, including only those PwMS who were from white ethnic backgrounds (online supplemental table 3). Similarly, those who were male, younger age at diagnosis or more recently diagnosed, were significantly more likely to start DMTs, regardless of their efficacies (table 2). Nagelkerke R2 values explained a 15% variation in starting moderate and high-efficacy DMTs.

Time to start DMTs and high-efficacy DMTs depended on ethnicity and deprivation respectively

KM survival analysis showed that time to starting any DMTs or high-efficacy DMTs did not depend on ethnicity or deprivation when various confounding factors were not taken into consideration (online supplemental figures 1 and 2). Cox proportional hazards regression models demonstrated that non-white ethnicity was a negative predictor for the time to starting any DMTs and had no impact on the time to starting high-efficacy DMTs and conversely, deprivation had no impact on the time to starting any DMTs but was a negative predictor for the time to starting high-efficacy DMTs (table 3 and online supplemental table 4). Interestingly, if the year of diagnosis was included in the model as a categorical variable, deprivation also had a negative impact on the time to starting any DMTs (online supplemental table 4). Overall, these findings, therefore, failed to consistently show an association between deprivation and time to starting any DMTs. Living in the least deprived areas (Q5) did not have any impact on the time to starting any DMTs or high-efficacy DMTs (online supplemental table 5). The impact of deprivation on the time to starting high-efficacy DMTs remained unchanged when corrected for reverse causality or when a sensitivity analysis was performed, including only those PwMS who were from white ethnic backgrounds (online supplemental table 6). Being male and more recently diagnosed were positive predictors, but age at diagnosis was a negative predictor for time to start DMTs, in particular high-efficacy DMTs (table 3).

Table 3

Impact of deprivation and ethnicity on the time to starting any DMTs and high-efficacy DMTs

PwMS from non-white ethnic backgrounds were more likely to decline DMTs

Among those 1413 PwMS who were offered DMTs; 1306 started DMTs, 78 declined DMTs, 21 were considering options to start DMTs at the time of data censoring and eight moved out of our service catchment area before starting DMTs. 62/1257 (5%) PwMS from white ethnic backgrounds declined DMTs whereas 16/148 (11%) people from non-white ethnic backgrounds declined DMTs (p=0.003). Online supplemental table 7 includes detailed demographic characteristics of those who declined DMTs. There was no difference in the proportion of females of childbearing age between white and non-white ethnicities (48% vs 50%) who declined DMTs (online supplemental table 7). Overall, the likelihood of declining DMTs did not depend on whether they were living in the most deprived (Q1) (p=0.348) or the least deprived (Q5) (p=0.403) areas. No specific reason for declining DMTs was provided by 44%, but others declined due to a number of reasons including family planning (13%), concern about side effects (12%), preferred alternative therapies (12%), needle and agoraphobia (10%), inability to attend hospitals for investigations and DMT monitoring (6%), preference for lifestyle modification instead of DMTs (4%) and feeling too well to start regular DMTs (3%). There were no significant differences in the reasons cited for declining DMTs between these two ethnic groups.

Health deprivation and disability domain of IMD may be the likely barrier to starting high-efficacy DMTs in PwMS from the most deprived areas

One of the seven IMD domains, health deprivation and disability, which measures the risk of premature death and the impairment of quality of life through poor physical or mental health, had an influence on starting high-efficacy DMTs, but not on the offer of DMTs by physicians. PwMS who live in the lowest quintile (Q1) of health deprivation and disability domain were less likely to start high-efficacy DMTs with OR of 0.69 (95% CI 0.51 to 0.94) compared with others (Q2–5) when adjusted for sex, age at diagnosis, year of diagnosis and ethnicity (online supplemental table 8). Similarly, the health deprivation and disability domain of IMD was a negative predictor in time to start high-efficacy DMTs (online supplemental table 9). This impact of deprivation remained unchanged when corrected for reverse causality or when a sensitivity analysis was performed, including only those PwMS who were from white ethnic backgrounds (online supplemental tables 10 and 11).

The other four domains of IMD unrelated to the affordability of drugs including education, skills and training, barriers to housing and services, crime and living environment, had no impact on offering or starting DMTs (online supplemental tables 8 and 9).

Discussion

In this single UK Neurosciences centre, the use of DMTs gradually increased over this 11 years of study period. Those who were diagnosed more recently or diagnosed at a younger age, were more likely to be offered and to start DMTs regardless of their efficacies. They also tended to start DMTs, particularly high-efficacy DMTs sooner. These findings reflect the data from the UK MS register (UKMSR).10 Reimbursement for DMTs in the UK until recently, has primarily been for relapsing-remitting than progressive forms of MS and was based exclusively on relapse criteria until the approval of ocrelizumab in July 2018, where active disease could then be defined more widely by ‘clinical or imaging features’. This, together with subsequent similar DMT approvals and emerging evidence of benefits from earlier use of high-efficacy DMTs, has resulted in a change in prescribing practice over recent years.18–20

After controlling for various confounding factors such as sex, deprivation, age at diagnosis and year of diagnosis, it appeared that MS specialists in our centre offered DMTs to PwMS from both ethnic groups equitably. However, despite PwMS from non-white ethnic backgrounds being on average 6 years younger at diagnosis, they were less likely to start DMTs than those from white ethnic backgrounds. This was probably because they were twice as likely to decline DMTs than those from white ethnicities. PwMS from non-white ethnicities were also more likely to experience delay in starting DMTs compared with those from white ethnicity. Further studies are required to investigate whether this delay is due to patient’s choice or systemic inequality within the healthcare system. PwMS from non-white ethnicities were also less likely to start high-efficacy DMTs than those from white ethnicities. However, there was no delay in starting high-efficacy DMTs in PwMS from non-white ethnicities. Further studies are required to understand the reason for this inequity in the uptake of high-efficacy DMTs in PwMS from non-white ethnicities.

PwMS from non-white ethnic backgrounds face inequality in accessing privately funded healthcare systems, which is largely driven by financial means.21 Ethnic inequity in publicly funded healthcare systems has been reported. In the UK, people from non-white ethnic backgrounds were less likely to have knee and hip replacement surgeries, self-refer to psychology services and participate in COVID-19 vaccine uptake. A number of factors that are thought to drive this inequality include language barriers, literacy, culture and structural racism leading to mistrust, doubt and ultimately disengagement with healthcare services and sourcing information for friends, family and social media.12–15

Although PwMS in the UK do not pay for their treatment, those living in the most deprived areas were less likely to be offered DMTs. In this study, the drivers of this inequity remain unknown. Further studies are required to investigate the mechanisms that cause this inequity. PwMS living in the most deprived areas were less likely to start high-efficacy DMTs. This inequality in starting high-efficacy DMTs appeared to be driven by health deprivation and disability, as measured in the IMD, although we were unable to adjust for their own MS-related disability levels, such as Expanded Disability Status Scale (EDSS) scores. Treatment with high-efficacy DMTs often requires frequent hospital visits for medication administration and monitoring. It is possible that PwMS living in the most deprived areas had difficulties visiting hospitals due to their disability levels resulting in this inequality in the uptake of high-efficacy DMTs. It is also possible that travel and other indirect non-reimbursed costs could be a barrier to frequent hospital visits from the most deprived areas. One previous study using the UKMSR data also showed that PwMS living in the most deprived areas were less likely to receive DMTs, which was thought to be driven by barriers to housing and services, suggesting reduced access to local neurology centres.7 In this study, from the analysis of the IMD domains, we did not find any barriers to housing and services within this catchment area, which contributed to inequity in accessing DMTs. In this cohort, PwMS from non-white ethnicities more frequently lived in deprived areas, but this negative influence of deprivation was not driven by ethnicity, as the findings of our study remained unchanged, even after sensitivity analyses that were performed by only including those who were from white ethnic backgrounds. Also living in the least deprived areas was not associated with better access to DMTs.

We also observed a prescribing bias based on sex, as males were more likely to be offered and subsequently to start both moderate and high-efficacy DMTs and were also likely to start DMTs, particularly high-efficacy DMTs sooner than females. MS natural history studies have shown that males have a more unfavourable prognosis than females, which could explain this bias.22 Further studies are required to understand the mechanism that drives this bias.

There are a number of limitations in this study. This was a single-centre experience and further multicentre studies are required to draw conclusions more widely regarding practice. It was a retrospective electronic health record analysis, although the 11-year study period mitigated against conscious minimisation of prescribing bias. Statistical models were not adjusted for individual disability levels such as EDSS, which could have been a confounding factor. Although overall a small proportion of PwMS declined DMTs at the end of the study period, this study did not capture the number of PwMS who initially declined, but subsequently deciding to start DMTs due to MS disease activity. In addition, specific reasons for declining DMTs were not available in half of these cases and this requires systematic capture in clinical practice. Qualitative studies are required to fully understand the impact of declining DMTs at an individual as well as health economic levels and to inform how services should address these concerns of PwMS. The non-white ethnic group includes PwMS from different ethnicities and their experience of accessing DMTs may differ. It is possible that deprivation and ethnicity influence the access to DMTs for MS in other ways. PwMS living the most deprived area or those from non-white ethnic backgrounds may present to primary and secondary care later than others. Data about their onset of MS symptoms, date of presenting to primary care or date of referral to secondary care were not available. Further studies are, therefore, required to examine the impact of deprivation and ethnicity on the access to MS care. Although a national study using UKMSR data suggested that deprivation influenced the access to DMTs through barriers to housing and services, this study suggested that deprivation exerted its influence on the access to high-efficacy DMTs through health deprivation and disability domain.10 In both of these studies, deprivation was measured using the postcode of residence. Location of residence or neighbourhood-based indices of deprivation provide a more collective measure of resources to which people have access, and adverse factors to which they are exposed. It is, therefore, a relative rather than absolute measure of deprivation at an individual level. Although this study informed how deprivation and ethnicity impact the access to DMTs, further qualitative studies such as structured or semistructured interviews of PwMS and staff surveys are required to understand the processes that drive these disparities along the whole patient pathway and to identify potential interventions that could improve health inequalities.

Conclusions

In this cohort of PwMS, diagnosed between 2010 and 2020, the offer of DMTs was equitable across white and non-white ethnic groups. However, those from a non-white background were more likely to decline DMTs resulting in being less likely to start DMTs regardless of their efficacies and were also more likely to experience a delay in starting DMTs. PwMS living in the most deprived areas, on one measure, were less likely to be offered DMTs. In addition, those from the most deprived areas were less likely to start high-efficacy DMTs and also experienced a delay in starting high-efficacy DMTs, which might have been associated with difficulty in frequently visiting hospitals due to their underling disability. These findings are highly relevant in designing equitable services for PwMS.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Ethics approval

The study complies with the Declaration of Helsinki and approval was obtained from the Research and Innovation Department, Northern Care Alliance NHS group (reference no: S21HIP21). As this was a retrospective observational study with full patient anonymity, the review board determined that the need for informed consent was not required.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors Planning: JD and DR; Conduct: JD and DR and Reporting: all authors. Responsible for the overall content as the guarantor: JD.

    We would like to acknowledge the Greater Manchester MS specialist nurses for their contribution to managing the MS regional caseload during the period covered by this study; Christine Allen, Alison Bradford, Gill Carter, Danielle Cragg, Daniel Dunbar, Adele Dillon, Fran Jackson, Nina Jennings, William Lusher, Wendy Power, Melanie Sutcliffe, Karen Vernon (MS Nurse Consultant) and Denise Winterbottom.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DR reports a relationship with Actelion, Biogen, Celgene, Hikma, Janssen, MedDay, Merck, Mitsubishi, Novartis, Roche, Sanofi, Teva, TG Therapeutics that includes consulting or advisory, funding grants and speaking and lecture fees.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.