COVID-19 pandemic has hardly stricken formal operational plans in many health centres, leading to a negative impact in patient care. With the present study, we evaluate standards of care in a single MS centre for the first time, during the first year of COVID-19 pandemic. This may serve as a useful learning process for future pandemics and other potential local or global severe disruptions of usual operations. Overall, clinical and radiological activity was maintained as a result of successful adaptations to face the pandemic . However, treatment strategies were subject to some variations which likely reflect a “change of concept” when treating MS patients during the COVID-19 pandemic.
The total number of clinical visits performed during 2020 remained stable in comparison with control periods, as the slight decrease observed during the “first wave” was rapidly corrected during the following months, thanks, at least in part, to rapid adoption of teleconsultation. Telemedicine had already been endorsed in terms of feasibility, cost-effectivity and patient satisfaction before the COVID-19 pandemic [21,22,23,24]. Interestingly, recent European and USA surveys have revealed that 73% of MS centres adopted telemedicine and one-third used telemedicine to provide over 75% of the clinical care during the first months of the pandemic, respectively [25, 26]. These figures clearly highlight the impressive capability of many MS centres to develop rapid structural adaptations. At our centre, up to a third of the whole outpatient clinical visits was performed via telemedicine by the end of 2020. This lower figure of telemedicine adoption in our centre may be explained by that the fact that, even though 30 out of 79 (38%) of Cemcat employees were either COVID-19-infected or quarantined in 2020, only 3 (3.8%) of them were physicians; in this way, resorting to telemedicine was only driven by patient needs and not due to low availability of physicians on site. In addition, Cemcat facilities are located in a stand-alone building, with its own route of access, and away from other clinical facilities in the Hospital campus; such location may have decreased the perception of contagion risk, thus favoring face-to-face visits. Altogether, both the prompt adaptation from face-to-face towards telemedicine visits as well as the centre architectural particularities were essential points to keep clinical requirements during the COVID-19 pandemic.
Radiology departments have been greatly impacted by COVID-19. Preliminary data from Yale New Haven Hospital, USA, revealed volume imaging drops greater than 50% . Another more recent international survey has shown that urgent MR scans were the only test allowed in 58% of centres, 17% of centres suspended or postponed radiological activity, and only 19% maintained usual activity . At our centre, radiological activity suffered a 73% abrupt reduction during the first two months of “the first wave” compared with overall activity in 2020, but showed a sharp recovery immediately after. The radiology department went through a deep reorganization to guarantee a low transmission risk which directly determined radiological dynamics during the first months of pandemic: redeployment of technicians and radiologist to cover COVID-19 activity, more extended intervals between and longer duration of MR scans due to hygienic measures and, finally, an increase of examinations associated with COVID-19-related neurological disorders . The overall stability of radiological activity observed across periods suggests that the initial activity decreased activity was not a consequence of variations in MR scan requests, but rather from rescheduling of non-urgent studies. Moreover, MR scan requests from primary care medicine were referred to other external centres, thus freeing slots to focus on radiological requests from our own centre, which greatly helped keeping the same levels of activity. Overall, the maintenance of the radiological activity after the first months of the pandemic indicates the adoption of first measures to be a key learning point to face the current or future pandemics.
MS therapy approach during the COVID-19 pandemic has been and still remains a challenge for MS neurologists trying to balance benefits and risks. Prescription of lympho-depleting agents in MS has been a matter of discussion due to the association with COVID-19 susceptibility and outcome risks [7, 29, 30]. Indeed, a survey has recently reported that 23% of centres avoided such therapies, whereas 8% postponed any type of DMD in treatment naïve-patients during the first months of the pandemic . Description of treatment strategies performed during the first year of the pandemic might be of interest to conduct an interim assessment of previous recommendations at a time when the effects of DMD on COVID-19 susceptibility and outcomes were still unknown . At our centre, treatment prescriptions during 2020 were lower than 2019, but similar to 2018. Whether COVID-19 pandemic was the only reason for such decrease might be difficult to ascertain since treatment prescription patterns depend on several un-controlled temporally related variables: number of patients derived to the MS centre, changes in treatment guidelines, number of on-going clinical trials or a lower rate of treatment-switches related to a wider use of highly effective drugs, among others. Since both the total number of yearly visits and radiological tests were unaffected in 2020 but treatment prescriptions modified, it needs to be considered that the rapid and wide adoption of telemedicine might have modified treatment prescription by physicians, by a number of different reasons (i.e., missing relapses and progression events or delaying final decision till next face-to-face visit). A different relationship between neurologist and patient, a lack of direct physical examination or even the absence of important non-verbal information are some of the consequences of a sudden shift from in-person visits to telemedicine . In fact, telemedicine may be better suited to other neurological diseases, such as epilepsy or headache, where the neurological examination is not a key point for decision-making . This should not be interpreted as a claim against telemedicine in MS, but rather suggests that telemedicine could be more beneficial in patients with stable disease forms and lower chances of treatment switch.
A non-pandemic-related decrease in prescription of anti-CD20 drugs during 2020 compared to 2019 may have also had an impact on the overall number of treatment prescriptions. Anti-CD20 drugs were approved to treat progressive MS forms by the end of 2018, producing a high number of prescriptions during 2019 compared to 2018. It is likely that important proportions of suitable patients for anti-CD20 drugs were treated during the first year after its approval, leaving therefore a small proportion of candidates to be treated during 2020. Obviously, a second potential cause for such decrease is the neurologist reluctance to prescribe anti-CD20 drugs due to the undesirable effects in the pandemic context [18, 32]. Whether the COVID-19 vaccine will modify anti-CD20 prescription patterns is still unknown, although previous experience suggests a decremental humoral response to vaccines in anti-CD20 MS treated patients when compared to other DMD . To this regard, most recent information points to an attenuated humoral response to COVID-19 vaccine in a non-negligible proportion of anti-CD 20 MS patients [34, 35]. An interesting finding corroborating a “change of concept” on treatment strategies during the pandemic comes from the higher number natalizumab prescriptions once the pandemic hit MS patients, in comparison to previous years. These data present natalizumab to be a comfortable and safety option for patients with a highly active disease that may had otherwise been proposed to initiate anti-CD20 or other lymphocyte-depleting drugs.
Because a pandemic cannot be foreseen, the nature of the present study entails those limitations associated with a retrospective design. In addition, some comments deserve to be added. First, the activity registered in a given health centre usually does not follow a linear pattern, but depends on un-controlled elements (i.e., disease incidence, hospital eligibility, course of the disease, etc.), which makes difficult to measure the direct impact of a pandemic on the clinical activity routine. As a proxy to identify pandemic-derived associations, outliers were defined as well as the inclusion of control periods before and after 2020, providing reasoned statements to consider these outliers as a direct consequence of the pandemic. Second, whether treatment prescriptions changes are a direct consequence of the COVID-19 pandemic or due to temporal fluctuations associated to intrinsic prescriptive patterns might be difficult to ascertain. Third, patients included in on-going clinical trials were not analyzed and, therefore, depicted figures do not show the whole spectrum of DMD used at our centre. Finally, the low sample sizes in some specific treatments prevented us to perform statistical comparisons. However, longitudinal descriptive analysis allowed us to show clear trends for anti-CD20 drugs or natalizumab.