Predictors of Mortality in Veterans with Multiple Sclerosis in an Outpatient Clinic Setting

Abstract

Activity Available Online: To access the article, post-test, and evaluation online, go to http://www.cmscscholar.org. Target Audience: The target audience for this activity is physicians, physician assistants, nursing professionals, and other health-care providers involved in the management of patients with multiple sclerosis (MS). Learning Objectives: 1) Describe factors associated with MS-related mortality 2) Identify strategies to address mortality risk factors in MS Accreditation Statement: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Consortium of Multiple Sclerosis Centers (CMSC), Nurse Practitioner Alternatives (NPA), and Delaware Media Group. The CMSC is accredited by the ACCME to provide continuing medical education for physicians. The CMSC designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurse Practitioner Alternatives (NPA) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NPA designates this enduring material for 1.0 Continuing Nursing Education credit [none in the area of pharmacology]. Laurie Scudder, DNP, NP, has served as Nurse Planner for this activity. She has disclosed no relevant financial relationships. Disclosures: Francois Bethoux, MD, Editor in Chief of the International Journal of MS Care (IJMSC), has served as Physician Planner for this activity. He has received royalties from Springer Publishing; consulting fees from Acorda Therapeutics, Merz Pharma, and Ipsen; and research support from Biogen, Acorda Therapeutics, and Adamas Pharmaceuticals. Laurie Scudder, DNP, NP, has served as Nurse Planner for this activity. She has disclosed no relevant financial relationships. Meheroz H. Rabadi, MD, MRCPI, FAAN, FANA, has disclosed no relevant financial relationships. Christopher E. Aston, PhD, has disclosed no relevant financial relationships. The anonymous peer reviewer for the IJMSC has disclosed no relevant financial relationships. The staff at the IJMSC, CMSC, NPA, and Delaware Media Group who are in a position to influence content have disclosed no relevant financial relationships. Method of Participation: Release Date: October 1, 2017 Valid for Credit Through: October 1, 2018 In order to receive CME/CNE credit, participants must: 1) Review the CME/CNE information, including learning objectives and author disclosures. 2) Study the educational content. 3) Complete the post-test and evaluation, which are available at http://www.cmscscholar.org. Statements of Credit are awarded upon successful completion of the post-test with a passing score of >70% and the evaluation. There is no fee to participate in this activity. Disclosure of Unlabeled Use: This CME/CNE activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. CMSC, NPA, and Delaware Media Group do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of CMSC, NPA, or Delaware Media Group. Disclaimer: Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health-care professionals without first evaluating their patients' conditions, considering possible contraindications or risks, reviewing any applicable manufacturer's product information, and comparing any therapeutic approach with the recommendations of other authorities. Background: Examining factors that increase risk of death in veterans with multiple sclerosis (MS) may help reduce MS-related mortality. We sought to determine predictors of mortality in veterans with MS attending an outpatient clinic. Methods: Review of electronic medical records of 226 veterans with MS regularly followed up from January 1, 2000, through December 31, 2014. Results: Mortality at the end of the 15-year study period was 14%. Patients with MS died prematurely, with a standardized mortality rate of 1.35 relative to the general (Oklahoma) population. The main causes of death documented were MS disease itself (57% of cases), infection (43%), and cancer and respiratory failure (18% each). Cox regression analysis using the whole cohort showed that progressive MS type; older age at entry into the study; presence of sensory, cerebellar, or motor (weakness and/or ataxia) concerns on presentation; more disability on presentation; higher body-mass index; being diabetic; never received disease-modifying therapy; and presence of pressure ulcers or neurogenic bladder were significant predictors of higher mortality. Conclusions: Initial presentation by MS type (progressive MS), higher level of disability, and associated motor, sensory, and cerebellar concerns are significant predictors of MS-related mortality. The main causes of death were MS disease itself, infection, respiratory disease, and cancer. More attention should be given to preventive strategies that delay mortality, such as yearly immunization and aggressively treating MS-related complications and diabetes mellitus.