Traffic Lights Intervention Reduces Therapeutic Inertia: A Randomized Controlled Trial in Multiple Sclerosis Care

Abstract

Background: Therapeutic inertia (TI) is a common phenomenon among physicians who care for patients with chronic conditions. We evaluated the efficacy of the traffic light system (TLS) educational intervention to reduce TI among neurologists with MS expertise. Methods: In this randomised, controlled trial, 90 neurologists who provide care to MS patients were randomly assigned to the TLS intervention ( n = 45) or to the control group ( n = 45). The educational intervention employed the TLS, a behavioral strategy that facilitates therapeutic choices by facilitating reflective decisions. The TLS consisted in a short, structured, single session intervention of 5-7 min duration. Participants made therapeutic choices of 10 simulated case-scenarios. The primary outcome was a reduction in TI based on a published TI score (case-scenarios in which a participant showed TI divided by the total number of scenarios where TI was possible ranging from 0 to 8). Results: All participants completed the study and were included in the primary analysis. TI was lower in the TLS group (1.47, 95% CI 1.32-1.61) compared to controls (1.93; 95% CI 1.79-2.08). The TLS group had a lower prevalence of TI compared to controls (0.67, 95% CI 0.62-0.71 vs. 0.82, 95% CI 0.78-0.86; p = 0.001). The multivariate analysis, adjusted for age, specialty, years of practice, and risk preference showed a 70% reduction in TI for the TLS intervention compared to controls (OR 0.30; 95% CI 0.10-0.89). Conclusions: In this randomized trial, the TLS strategy decreases the incidence of TI in MS care irrespective of age, expertise, years for training, and risk preference of participants, which would lead to better patient outcomes.

Effect of an Educational Intervention on Therapeutic Inertia in Neurologists With Expertise in Multiple Sclerosis

“…We applied a previously proven effective TLS intervention 9 to facilitate the identification of patients at high risk of disease progression (based on clinical and imaging evidence of disease progression)…”

“…The TLS supports the decision-making process by use of established associations between traffic light colors and actions to stop or proceed. 9,[18][19][20] For example, in the context of this intervention, a red light represents high risk and triggers a stop and think action, whereas a green light represents low risk and a triggers a continue the same strategy action. A previous study reported that the TLS can interrupt automatic behavior and lead to more optimal decision-making.…”

“…Effect of an Educational Intervention on Therapeutic Inertia in Neurologists With Expertise in Multiple Sclerosis outcome included TI greater than or equal to 25% of responses, meaning that participants did not escalate treatment when recommended in at least 1 of 4 simulated case scenarios. [9][10][11][12]…”

“…[3][4][5]8 A randomized clinical trial on MS care reported a 70% reduction of TI in neurologists, using a short (<5 minutes) and simple (application of the traffic light system [use of established associations between traffic light colors and actions to stop or proceed]) educational intervention. 9 For MS care, overcoming TI corresponds to appropriately switching from a first-line agent (eg, glatiramer or interferon) to a high-efficacy treatment (eg, fingolimod or monoclonal antibodies) when given both clinical and radiologic evidence of disease progression. [9][10][11][12][13] Recent studies reported that decision-making in the context of uncertainty is associated with autonomic arousal, as measured by pupil dilation.…”

“…9 For MS care, overcoming TI corresponds to appropriately switching from a first-line agent (eg, glatiramer or interferon) to a high-efficacy treatment (eg, fingolimod or monoclonal antibodies) when given both clinical and radiologic evidence of disease progression. [9][10][11][12][13] Recent studies reported that decision-making in the context of uncertainty is associated with autonomic arousal, as measured by pupil dilation. 14,15 In particular, phasic pupil size increases are associated with suboptimal or erroneous decision-making involving high uncertainty.…”