Geographic determinants of health: location, location


Geography has a significant impact on MS patients’ access to care and treatment options, according to data presented at the Consortium of MS Centers (CMSC) 38th annual meeting, held May 29-June 1 in Nashville, Tennessee.

About 25% of MS patients live in “MS care deserts”, defined as >60 minutes’ travel time to an MS neurologist or specialist centre, according to one U.S. study (Barnola et al. CMSC 2024;LB03). Urban centres were adequately served with a neurologist density of 10.8/100,000 population, but density was low (2.2/100,000) in the rest of the U.S. By comparison, the estimated neurologist density for all of Canada is 2.2/100,000 with the majority practising in large (>500,000) urban centres (Kirby et al. Can J Neurol Sci 2016; 43: 227-237).

MS patients’ lack of access to healthcare resources is also apparent in recent U.S. surveys. In a study by Rivera and colleagues (N=620), one-third of respondents (33.1%) said they could not find MS care in their community, 31.0% said they had difficulty finding a doctor in their area to coordinate their care, and 18.6% said they lacked access to transportation (Rivera et al. CMSC 2024;QOL20).

Telehealth initiatives were intended to improve access to care during the pandemic, most notably for those living outside of major urban centres (Hatcher-Martin et al. Neurology 2020;94:30-38). However, Health Canada has acknowledged that telemedicine may well exacerbate rather than alleviate geographic and other barriers to access (Health Canada 2021; For example, a NARCOMS survey found that telehealth video visits were less common among disadvantaged groups, such as the elderly and those with greater impairments (Marrie et al. Neurol Clin Pract 2022;12:223-233). Telephone contact can be made in rural areas where videoconferencing is unavailable but generally provides suboptimal care (Giacomini et al. Can J Neurol Sci 2024;51:113-116).

Geography will also affect access to treatment and the choice of disease-modifying therapy (DMT). In some Canadian provinces, DMTs can only be prescribed by clinicians affiliated with an MS clinic. Thus, patients who live remote from a clinic cannot access treatment. This was shown in a B.C. study that found that 42% of MS patients were not registered with an MS clinic; only 1% of this group were being treated with a DMT (McKay et al. Eur J Neurol 2016;23:1093-1100).

Moreover, a study in Alberta recently reported that MS patients living in a rural setting were less likely to be prescribed a DMT (27.4%) than those living in a city such as Calgary (32.1%) or Edmonton (32.8%) (Balcom et al. Can J Neurol Sci 2024; epublished April 11, 2024). The choice of therapy also differed according to geography. Rural MS patients were more likely to be prescribed a platform therapy and less likely to receive a high-efficacy DMT, such as a monoclonal antibody. This is likely due to differences in prescribing: community neurologists and other physicians not affiliated with an MS centre are less likely to prescribe a high-efficacy DMT.

Another contributing factor may be the difficulty associated with visiting an infusion centre. A U.S. study analysed the travel burden for MS patients (N=36,599) receiving an infusion DMT (Ming-Hui et al. CMSC 2024;DMT37). The database analysis looked at commuting times for MS patients who received a therapy (natalizumab, ocrelizumab, alemtuzumab, ublituximab) at an infusion centre over a five-year period. Mean age was 54 years, 70% lived in urban centres, and 72% received ocrelizumab. Overall, the mean distance travelled was 54 miles; for rural patients, 22% travelled >120 miles to an infusion centre. The mean travel time was 95 minutes (78 minutes for urban, 125 minutes for rural). It should be noted that travel times do not include the time burden due to prolonged infusion times.

Thus, the inequitable distribution of infusion centres may contribute to current disparities in patient management and clinical outcomes in the urban versus rural setting. The more favourable benefit-risk profile of anti-CD20 agents and the increasing use of higher-efficacy DMTs that can be self-administered in the home (e.g. ofatumumab, oral cladribine) may enable more widespread use of highly effective therapy in patients living in remote centres and other disadvantaged populations and patients living in remote regions.

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