title: Herding: a new phenomenon affecting medical decision-making in multiple sclerosis care? Lessons learned from DIScUTIR MS.
abstract: OBJECTIVE
  Herding is a phenomenon by which individuals follow the behavior of others rather than deciding independently on the basis of their own private information. A herding-like phenomenon can occur in multiple sclerosis (MS) when a neurologist follows a therapeutic recommendation by a colleague even though it is not supported by best practice clinical guidelines. Limited information is currently available on the role of herding in medical care. The objective of this study was to determine the prevalence (and its associated factors) of herding in the management of MS.
  
  
  METHODS
  We conducted a study among neurologists with expertise in MS care throughout Spain. Participants answered questions regarding the management of 20 case scenarios commonly encountered in clinical practice and completed 3 surveys and 4 experimental paradigms based on behavioral economics. The herding experiment consisted of a case scenario of a 40-year-old woman who has been stable for 3 years on subcutaneous interferon and developed a self-limited neurological event. There were no new magnetic resonance imaging (MRI) lesions. Her neurological examination and disability scores were unchanged. She was advised by an MS neurologist to switch from interferon to fingolimod against best practice guidelines. Multivariable logistic regression analysis was conducted to evaluate factors associated with herding.
  
  
  RESULTS
  Out of 161 neurologists who were invited to participate, 96 completed the study (response rate: 60%). Herding was present in 75 (78.1%), having a similar prevalence in MS experts and general neurologists (68.8% vs 82.8%;P=0.12). In multivariate analyses, the number of MS patients seen per week was positively associated with herding (odds ratio [OR] 1.08, 95% CI 1.01-1.14). Conversely, physician's age, gender, years of practice, setting of practice, or risk preferences were not associated with herding.
  
  
  CONCLUSIONS
  Herding was a common phenomenon affecting nearly 8 out of 10 neurologists caring for MS patients. Herding may affect medical decisions and lead to poorer outcomes in the management of MS.
authors.affiliation: Division of Neurology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada; Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland; Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Saposnik
authors.affiliation: Neuroscience Area, Medical Department, Roche Farma, Madrid.
authors.forename: Jorge
authors.initials: J
authors.lastname: Maurino
authors.affiliation: Department of Neurology, Hospital General Universitario de Alicante, Alicante, Spain.
authors.forename: Angel P
authors.initials: AP
authors.lastname: Sempere
authors.affiliation: Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland.
authors.forename: Christian C
authors.initials: CC
authors.lastname: Ruff
authors.affiliation: Laboratory for Social and Neural Systems Research, Department of Economics, University of Zurich, Zurich, Switzerland.
authors.forename: Philippe N
authors.initials: PN
authors.lastname: Tobler
keywords: decision-making; disease-modifying therapy; herding; multiple sclerosis; neuroeconomics; risk aversion