title: Decision-making in Multiple Sclerosis: The Role of Aversion to Ambiguity for Therapeutic Inertia among Neurologists (DIScUTIR MS).
abstract: OBJECTIVE
  Limited information is available on physician-related factors influencing therapeutic inertia (TI) in multiple sclerosis (MS). Our aim was to evaluate whether physicians' risk preferences are associated with TI in MS care, by applying concepts from behavioral economics.
  
  
  METHODS
  In this cross-sectional study, participants answered questions regarding the management of 20 MS case scenarios, completed 3 surveys, and 4 experimental paradigms based on behavioral economics. Surveys and experiments included standardized measures of aversion ambiguity in financial and health domains, physicians' reactions to uncertainty in patient care, and questions related to risk preferences in different domains. The primary outcome was TI when physicians faced a need for escalating therapy based on clinical (new relapse) and magnetic resonance imaging activity while patients were on a disease-modifying agent.
  
  
  RESULTS
  Of 161 neurologists who were invited to participate in the project, 136 cooperated with the study (cooperation rate 84.5%) and 96 completed the survey (response rate: 60%). TI was present in 68.8% of participants. Similar results were observed for definitions of TI based on modified Rio or clinical progression. Aversion to ambiguity was associated with higher prevalence of TI (86.4% with high aversion to ambiguity vs. 63.5% with lower or no aversion to ambiguity;p= 0.042). In multivariate analyses, high aversion to ambiguity was the strongest predictor of TI (OR 7.39; 95%CI 1.40-38.9), followed by low tolerance to uncertainty (OR 3.47; 95%CI 1.18-10.2).
  
  
  CONCLUSIONS
  TI is a common phenomenon affecting nearly 7 out of 10 physicians caring for MS patients. Higher prevalence of TI was associated with physician's strong aversion to ambiguity and low tolerance of uncertainty.
authors.affiliation: Division of Neurology, Stroke Outcomes and Decision Neuroscience Research Unit, 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: Department of Neurology, Hospital General Universitario de Alicante , Alicante , Spain.
authors.forename: Angel P
authors.initials: AP
authors.lastname: Sempere
authors.affiliation: Neuroscience Area, Medical Department, Roche Farma , Madrid , Spain.
authors.forename: Daniel
authors.initials: D
authors.lastname: Prefasi
authors.affiliation: Division of Neurology, Stroke Outcomes and Decision Neuroscience Research Unit, Department of Medicine, St. Michael's Hospital, University of Toronto , Toronto, ON , Canada.
authors.forename: Daniel
authors.initials: D
authors.lastname: Selchen
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: Neuroscience Area, Medical Department, Roche Farma , Madrid , Spain.
authors.forename: Jorge
authors.initials: J
authors.lastname: Maurino
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; multiple sclerosis; neuroeconomics; risk aversion