Discussing Disparities in MS Care for Underrepresented Populations

Dr. Turck:
Welcome to NeuroFrontiers on ReachMD. I'm Dr. Charles Turk, and joining me today about the challenges faced by patients with multiple sclerosis in underrepresented populations is Dr. Tirisham Gyang and Dr. Gopika Kutty. Dr. Gyang is a Clinical Assistant Professor of Neurology at the Ohio State University School of Medicine, and Dr. Kutty is a Neurologist at the University of Pittsburgh Medical Center. Together, we'll be discussing their recent publication, titled “Disparities in Multiple Sclerosis, Incorporating Equity into Clinical Care and Research,” which was published in Practical Neurology in July 2023. Dr. Gyang and Dr. Kutty, thanks for being here today.

Dr. Gyang:
Thank you so much, Dr. Turck. We're really happy to be here.

Dr. Kutty:
Thank you for having us, Dr. Turck.

Dr. Turck:
Well, to start us off, Dr. Gyang, would you explain how the clinical presentation of MS differs race and ethnicity?

Dr. Gyang:
Sure. I could go ahead with that. So in the past, when we studied MS, it was seen that this was a disease that was more prevalent in White individuals from Northern European ancestry. However, more recent data is coming out that MS can happen in anyone and everyone. But an interesting fact that we see is that there may be slight clinical variations in the disease when we look at different demographic populations. So a lot of studies have shown that when we look at whether it's MRI data, relapses, time to disability OCT data, looking behind the eyes, we see that certain groups have a more accelerated progression or more accelerated time to get to a certain disability point. And so there's a lot of studies that are going into looking at these differences. Why are we seeing these differences? What are the main factors driving differences when we look at different demographic groups? And so yes, there is a difference. It's the same disease, but we're seeing an uptake and more cases of MS in minority populations, including Hispanic and African-American groups. And it's probably under-recognized in these groups because the thought of just this not being prevalent in these groups maybe has led to under-diagnosis. But then we're seeing that there's slight difference, or some degree of presentation, with certain groups having a more aggressive form of the disease than others.

Dr. Turck:
Over to you, Kutty. What else can you tell us about the prevalence and incidence of MS in underrepresented populations?

Dr. Kutty:
So I would just go to a recent study that came out in JAMA Neurology, which was a large population-based cohort study that looked at the prevalence data in different demographic groups. So the study actually looked at three years data between 2008 to 2010 based on 96 million insurance claims.

And what it showed was still there is a high prevalence in White individuals, followed by Blacks, and followed by non-Hispanics and other racial groups, and followed by Hispanic groups. So again, the prevalence still continues to be high in White individuals that we already know. Again, the important thing here is the increased incidence in the other racial groups, such as Blacks and Hispanics. And that increased incidence has also led to the increased prevalence in those underrepresented population, which is much more than what we knew before. So that is regarding the prevalence and incidence. Now if we look at other factors, such as sex or gender, I think the study still showed it was about 77 percent individuals with MS were females and the rest were males. So there is still that higher sex ratio in females compared to males.

Dr. Turck:
And, Dr. Gyang, are there any disparities in MS treatment in the populations we've been discussing?

Dr. Gyang:
So we talked a little bit about the fact that for a very long time the belief was that MS is very rare in individuals that are not White or of northern European ancestry. And so that has led to maybe some under-diagnosis of MS in these groups, late diagnosis in these groups, and sometimes late diagnosis can lead to poor outcomes. And so we see these differences in clinical presentation, and the question always comes, what is driving the differences? Is this biologic? Is this genetic? Is it social? Are people, certain groups just not having enough access to health care or is this a bias in the medical community where we're not recognizing MS early enough in these demographic groups to start those treatments very early? Because from what we understand, once a patient is diagnosed, you want to get them on a treatment fast and control the disease. That typically predicts long term disability.  So yes, there is a difference in clinical representation and how aggressive the disease presents itself in these groups. And the question always comes, what are the factors driving that difference? And I think it's multifactorial. And so more research needs to go into this just to understand what these differences are and just awareness among health community that MS can happen in everyone, and we need to start treatments very early in MS.

Dr. Turck:
For those just tuning listening to NeuroFrontiers on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Tirisham Gyang and Dr. Gopika kutty about patients with multiple sclerosis in underrepresented populations. So coming back to you, Dr. Kutty, how could we work to overcome barriers to equitable treatment of MS in these populations and provide better care?

Dr. Kutty:
Yeah, so that's a very challenging and complex situation, so here we have to definitely think about the social determinants of health, which includes socioeconomic status, health literacy, education, accessibility to health care, affordability. So there's a lot of social components here. And first of all, I think considering each patient's needs, whether it is for transportation assistance, whether it is for accessibility, whether it's the resources that they need, I think that needs to be identified, not just by the provider who's taking care of them, but also as a group, as a practice, and also in the community. So this needs the interaction with community outreach programs policy makers and leaders. So I think that's where it's a challenging situation, but I think that's how we could overcome some of these barriers.

Dr. Turck:
And, Dr. Gyang, are there other unmet needs we haven't yet discussed that are covered in your paper?

Dr. Gyang:
Yes, so men are a minority group in MS if you're looking at the MS population. And when we look at clinical outcomes, men also tend to have more disability. Men tend to have more of the progressive phenotypes of MS. The disability tends to be more rapid in progression when we compare to women. And so the other question to ask as well is what is driving this? Is this something that's biologic based on the sex hormones that carry those differences between the two genders and what exactly is driving the differences in clinical representation? And so men as a minority group, I think we definitely need to pay attention to giving the adequate care, making sure we're giving the appropriate treatments to halt relapses, to halt disease progression so that we don't have an accumulation of disability over time. So I think we mentioned a few different facts about MRI data in men, just the accelerated progression that we see.

And it doesn't mean every man with MS does poorly, but in general, as a group, men tend to have more disability than women. And this is something that providers need to be aware of as well. And we want to diagnose this early. We want to be able to give the appropriate treatments very early, and then provide the services, whether it's social work, physical therapy, occupational therapy, mental health therapy, like whatever is needed, we need to provide those services on time because if you're underrepresented in a certain group, there may be factors that impair you getting the adequate help you need.

Dr. Turck:
Now before we close, Dr. Kutty, what other research needs to be done to help reduce these disparities in care?

Dr. Kutty:
Yeah, so historically, individuals from minority groups have been underrepresented in clinical research and clinical trial. So most importantly, I think inclusion of all racial or ethnic or other minority subgroups are definitely important so that we can better understand the disease outcomes, and secondly, we need inclusion in not just demographic studies or just estimates of population based studies, but we also need to look into clinical factors. We also need drug clinical trials and other factors that would look at if it's just the interplay of genetic, social, and environmental factors and how they are going to affect each minority or racial groups so that we better understand the disease, how they are affecting each minority group.

Dr. Turck:
This has been an insightful look at the present  disparities in multiple sclerosis care and how we can hopefully overcome these challenges. Dr. Gyang, thanks so much for joining me today.

Dr. Gyang:
Thanks for having us.

Dr. Turck:
And, Dr. Kutty, it was a pleasure speaking with you as well.

Dr. Kutty:
Thank you so much.

Dr. Turck:
For ReachMD, I'm Dr. Charles Turk. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.