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. 2025 Feb 11;104(3):e210251.
doi: 10.1212/WNL.0000000000210251. Epub 2025 Jan 7.

Inequities in the Use of Disease-Modifying Therapy Among Adults Living With Multiple Sclerosis in Urban and Rural Areas in Alberta, Canada

Erin F Balcom  1 , Jennifer A Mccombe  1 , Mahesh P Kate  1 , Khanh Vu  2 , Karen J B Martins  1 , Sylvia Aponte-Hao  3 , Lawrence Richer  4 , Tyler Williamson  5 , Scott W Klarenbach  6 , Penelope S Smyth  1
Affiliations

Inequities in the Use of Disease-Modifying Therapy Among Adults Living With Multiple Sclerosis in Urban and Rural Areas in Alberta, Canada

Erin F Balcom et al. Neurology. .

Abstract

Objectives: To compare disease-modifying therapy (DMT) use between people living with multiple sclerosis (pwMS) who resided in rural vs urban areas.

Methods: This retrospective cohort study used population-level individually linked administrative data to identify pwMS on April 1, 2019 (index date), in Alberta, Canada. DMT use was compared between pwMS who resided in rural vs urban areas during a 1-year postindex period. Structural equation modelling (SEM) and logistic regression (with 95% confidence intervals) were applied.

Results: PwMS (n = 4,593) who resided in rural areas (vs urban) were 17% less likely to have received a DMT (odds ratio: 0.83 [0.69-0.99]; SEM total β: -0.032, p < 0.05), of which 39% of this disparity was explained by a lower socioeconomic status (SEM indirect β: -0.012 [p < 0.001]/total β: -0.032); 26% were less likely to have received an induction/higher efficacy therapy (odds ratio: 0.74 [0.57-0.95]), of which <1% of this disparity was explained by socioeconomic status (SEM indirect β: -0.0001 [p < 0.01]/total β: -0.040).

Discussion: PwMS residing in rural (vs urban) Alberta are less likely to receive any DMT, especially induction/higher-efficacy therapy; this inequality may be mediated by socioeconomic status and geography. Identifying and overcoming barriers to optimal clinical care in this patient population is needed.

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Conflict of interest statement

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this manuscript: K. Vu, K.J.B. Martins, S. Aponte-Hao, L. Richer, T. Williamson, and S.W. Klarenbach are members of the Alberta Real World Evidence Consortium (ARWEC) and/or the Alberta Drug and Therapeutic Evaluation Consortium (ADTEC); these entities (composed of individuals from the University of Alberta, University of Calgary, and Institutes of Health Economics) conduct research including investigator-initiated industry-funded studies (ARWEC) and government-funded studies (ADTEC). E.F. Balcom, J.A. Mccombe, M.P. Kate, and P.S. Smyth declare no competing interests. All authors of this study had complete autonomy over the content and submission of the manuscript, as well as the design and execution of the study. Go to Neurology.org/N for full disclosures.

Figures

Figure 1
Figure 1. Final Structural Equation Model of the Relationship Between Geographical Residence (Rural vs Urban; Exposure) and DMT Use (Use vs None; Outcome)
Confounders included age (>60 vs ≤60 years), Charlson Comorbidity Index score (one score higher vs lower; continuous), comorbidities (living with a certain comorbidity vs not), and years living with MS (number of years since the MS incident date); socioeconomic status (material deprivation index score of 1 [most privileged] vs 2–5 [less privileged]) was a mediator. Model goodness-of-fit: χ2 = 118.0, degree of freedom (df) = 45, χ2/df ratio = 2.6, SRMR = 0.05, RMSEA = 0.02, CFI = 0.94, AGFI = 1.00. *Statistical significance at p < 0.05. COPD = chronic obstructive pulmonary disease; DMT = disease-modifying therapy; MS = multiple sclerosis.
Figure 2
Figure 2. Final Structural Equation Model of the Relationship Between Geographical Residence (Rural vs Urban; Exposure) and DMT Use by Type (Use vs None; Outcome)
Confounders included age (>60 vs ≤60 years), Charlson Comorbidity Index score (one score higher vs lower; continuous), comorbidities (living with a certain comorbidity vs not), and years living with MS (number of years since the MS incident date); socioeconomic status (material deprivation index score of 1 [most privileged] to 2–5 [less privileged]) was a mediator. Model goodness-of-fit: χ2 = 131.5, df = 53, χ2/df ratio = 2.5, SRMR = 0.05, RMSEA = 0.02, CFI = 0.94, AGFI = 0.99. *Statistical significance at p < 0.05. COPD = chronic obstructive pulmonary disease; DMT = disease-modifying therapy; MS = multiple sclerosis.
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