AUTHOR=Saposnik Gustavo , Maurino Jorge , Sempere Angel P. , Terzaghi Maria A. , Ruff Christian C. , Mamdani Muhammad , Tobler Philippe N. , Montalban Xavier 

TITLE=Overcoming Therapeutic Inertia in Multiple Sclerosis Care: A Pilot Randomized Trial Applying the Traffic Light System in Medical Education

JOURNAL=Frontiers in Neurology

VOLUME=Volume 8 - 2017

YEAR=2017

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2017.00430

DOI=10.3389/fneur.2017.00430

ISSN=1664-2295

ABSTRACT=Background: Physicians often do not initiate or intensify treatments when clearly warranted, a phenomenon known as therapeutic inertia (TI). We evaluated the feasibility and efficacy of an educational intervention compared to usual care among practicing neurologists caring for patients with multiple sclerosis (MS).
Methods:  We conducted a pilot double-blind, parallel-group, randomised clinical trial. Inclusion criteria included neurologists who are actively involved in managing MS patients. Participants were exposed to 20 simulated case-scenarios (10 cases at baseline, and 10 cases post-randomization to usual care vs. educational intervention) of relapsing-remitting MS with moderate or high risk of disease progression. The educational intervention employed a traffic light system to facilitate decisions, allowing participants to easily recognize high-risk scenarios requiring treatment escalation. The control group responded as they would do in their usual clinical practice not exposed to the educational intervention. The primary feasibility outcome was the proportion of participants who completed the study and the proportion of participants who correctly identified a high-risk case-scenario with the ‘red traffic light’. Secondary outcomes included decision fatigue and the efficacy of the educational intervention measured as a reduction in TI for MS treatment. 
Results: Of 30 neurologists invited to be part of the study, the participation rate was 83.3% (n=25). Of the 25 participants, 14 were randomly assigned to the control group and 11 to the intervention group. TI was present in 72.0% of participants in at least one case scenario. For the primary feasibility outcome, the completion rate of the study was 100% (25/25 participants). Overall, 77.4% of participants correctly identified the ‘red traffic light’ for clinical-scenarios with high-risk of disease progression. Similarly, 86.4% of participants correctly identified the ‘yellow traffic light’ for cases that would require a reassessment within 6 to 12 months.  For the secondary fatigue outcome, within-group analysis showed a significant increased prevalence of TI in the second block of case-scenarios.  
Conclusions: An educational intervention applying the traffic light system is feasible and shows some promising results in the identification of high-risk scenarios to reduce decision fatigue and TI. Larger studies are needed to determine the efficacy of the proposed educational intervention.