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Multichannel sequence analysis: An innovative method to study patterns of care pathways. Application to multiple sclerosis based on French Health Insurance data

Abstract : IntroductionMultiple sclerosis (MS) is a chronic neurological disease starting in young adulthood and leading to disability on the long-term. Persons with MS (PwMS) require multidisciplinary care involving general practitioners (GPs), neurologists as well as specialists of disability symptoms (frequently, physical medicine and rehabilitation physician, urologist, and ophthalmologist). The coordination and succession of these interventions constitute the care pathway of a patient. Even if a care pathway is unique for each patient, patterns of pathway can emerge. Identification of such patterns may be helpful for optimizing comprehensive care for PwMS and understanding variations within practices (if any). There is a current lack of statistical or epidemiological methods allowing for identification of such patterns. Therefore, we propose an innovative method, which is derived from social sciences: the multichannel sequence analysis (MCSA).MethodsAn exhaustive study population was formed of the prevalent PwMS in the French national health insurance databases (97% of French population covered), who were alive on January 1st, 2010 (N=73,619) and who did not die over the 2010–2015 period (N=69,831). PwMS were identified thanks to a three-criterion algorithm using diagnoses of hospital admissions, MS-specific disease-modifying therapies and MS long disease duration status. Because of computational resources, a random sample of 35,000 PwMS has then been selected to apply MCSA. Care consumptions of interest considered on a 6-month time unit basis were: consultations with GPs, private neurologists and specialists of disability symptoms, and length of hospital stay(s) for MS (main or related diagnosis coded G35 according to International Classification of Diseases, 10th version). MCSA permits to consider several dimensions of the individual care pathway simultaneously. Indeed each individual was associated with several distinct but synchronized sequences, the so-called channels, each tapping a distinct aspect (each healthcare professional here) of the global pathway. All multichannel care pathways were compared two-by-two leading to a matrix of dissimilarities, which was then used in a hierarchical agglomerative clustering using Ward's criterion. The typology was then described based upon the simultaneous interpretation of each channel of the trajectory.ResultsThe sex-ratio F:M of the study population (N=35,000) was 2.6 with a median age of 49 years in 2010. In total, the median number of visits with GPs, neurologists, and specialists of disability symptoms were 4.8, 0.2, 0.2 visits per year, respectively. MCSA revealed a 5-cluster typology of care consumption. A first group (n=3965, 11.3%) corresponded to young patients (median age of 43 years in 2010) having in median 5.3 visits with GPs per year and 6.3 days of hospital stays per year. The 11,690 patients (33.4%) in the second group were older with a moderate contact with GPs (5.2 visits per year). The main characteristic of the third group (n=11,696, 33.4%) was their routine follow-up by private neurologists (1.8 visits per year in median). The fourth group (n=2437, 7.0%) included the oldest patients (median age of 55 years in 2010) having a very high contact with GPs (15 visits per year) probably because of comorbidities and a progressive or evolved MS disease. The 5212 patients in the fifth group (14.9%) had a lack of care consumption during the study period with in median 0.0 visits with each specialist considered in the analysis.ConclusionsUsing a pioneer and easy-to-use method, this study highlights for the first time five different patterns of care pathways of PwMS in France. To get a more accurate examination of the care pathways, paramedical care (especially nurses and physiotherapists) is going to be included as a channel in the analysis. In our opinion, MCSA is a promising way to study care pathways and deserves consideration in epidemiology.
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Jonathan Roux, Olivier Grimaud, Emmanuelle Leray. Multichannel sequence analysis: An innovative method to study patterns of care pathways. Application to multiple sclerosis based on French Health Insurance data. Epidemiology and Public Health = Revue d'Epidémiologie et de Santé Publique, Elsevier Masson, 2018, 66, pp.S430-S431. ⟨10.1016/j.respe.2018.05.534⟩. ⟨hal-02921552⟩



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