The impact of educational attainment on diagnostic and treatment delays in multiple sclerosis: a nationwide cohort study in Denmark

Elisabeth Framke¹, Melinda Magyari^{2

3

4}; DMSG Study Group

Collaborators, Affiliations

Collaborators

DMSG Study Group:
Alex Heick⁵, Ana Isabel Figueira Jensen⁵, Anja Thormann⁵, Finn Sellebjerg⁶, Jeppe Romme Christensen⁵, Jesper Nørregaard⁵, Jette Lautrup Frederiksen⁶, Julie Richter Hansen⁵, Karen Ingrid Schreiber⁵, Morten Blinkenberg⁵, Per Soelberg Sørensen⁵, Rikke Marie Jensen⁵, Stephan Bramow⁷, Thor Chalmer⁵, Viktoria Papp Papp⁵, Melinda Magyari⁸, Nils Koch-Henriksen⁹, Morten Leif Munding Stilund¹⁰, Henrik Kahr Mathiesen¹¹, Henrik Boye Jensen¹², Egon Stenager¹³, Mai Bang Poulsen¹⁴, Michael Langemark¹⁴, Michael Broksgaard Jensen¹⁴, Nadia Mubder Issa¹⁴, Ásta Milthers Theódórsdóttir¹⁵, Helle Hvilsted Nielsen¹⁶, Manuel Demirovic¹⁵, Zsolt Laszlo Illés¹⁶, Homayoun Roshanisefat¹⁷, Nasrin Asgari¹⁸, Afzal Gardezi¹⁹, Matthias Kant¹⁹, Thor Petersen¹⁹, Tobias Sejbæk²⁰, Claudia Christensen²¹, Inga Urbonaviciute²², Ismael Barzinji²¹, Jakob Schäfer²¹, Camilla Mærsk-Møller²³, Caroline Winther Tørring²³, Kristina Bacher Svendsen²³, Peter Vestergaard Rasmussen²³, Georgi P Sirakov²⁴, Sivagini Prakash²⁴, Tsvetomir Asenov²⁴, Lars Kristian Storr²⁵, Lena Christina Roug²⁵, Monika Katarzyna Góra²⁵, Said Ashna²⁵

Affiliations

¹ The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Valdemar Hansens Vej 2, Entrance 8, Second Floor, DK-2600 Glostrup, Denmark.
² The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Glostrup, Denmark.
³ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Glostrup, Denmark.
⁴ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
⁵ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark.
⁶ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
⁷ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet ; Valdemar Hansens Vej 13, 2600 Glostrup, Denmark.
⁸ The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark; Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
⁹ The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark; Department of Clinical Epidemiology, Clinical Institute, University of Aarhus, Olof Palmes Allé 43-45, 8200 Aarhus N.
¹⁰ Gødstrup Hospital, Department of Neurology, Physiotherapy and Occupational Therapy, Hospitalsparken 15, 7400 Herning, Denmark; NIDO | Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 25, 7400 Herning, DenmarkArkadiusz Weglewski, MD, PhD, Department of Brain and Nerve Diseases, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
¹¹ Department of Brain and Nerve Diseases, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
¹² Lillebælt Hospital, Department of Brain and Nerve Diseases, Sygehusvej 24, 6000 Kolding, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
¹³ Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
¹⁴ North Zealand Hospital, Copenhagen University Hospital, Department of Neurology, Dyrehavevej 29, 3400 Hillerød, Denmark.
¹⁵ Odense University Hospital, Department of Neurology, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
¹⁶ Odense University Hospital, Department of Neurology, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
¹⁷ Slagelse Hospital, Department of Neurology, Fælledvej 11, 4200 SlagelseMasoud Falah, MD, Slagelse Hospital, Department of Neurology, Fælledvej 11, 4200 Slagelse.
¹⁸ Slagelse Hospital, Department of Neurology, Fælledvej 11, 4200 Slagelse, Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
¹⁹ Hospital of Southern Jutland, Department of Neurology, University of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark.
²⁰ Southwest Jutland Hospital, Department of Neurology, University Hospital of Southern Denmark, 6700 Esbjerg, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
²¹ Aalborg University Hospital, Department of Neurology, Reberbanegade 15, 9100 Aalborg, Denmark.
²² Aalborg University Hospital, Department of Neurology, Reberbansgade 15, 9100 Aalborg, Denmark.
²³ Aarhus University Hospital, Department of Neurology, PJJ Boulevard 165, J504, 8200 Aarhus N, Denmark.
²⁴ Regionshospital Viborg, Hospitalsenhed Midt, Department of Neurology, Heibergs Allé 4, 8800 Viborg.
²⁵ Zealand University Hospital, Department of Neurology, Sygehusvej 10, 4000 Roskilde, Denmark.

PMID: 39958832
PMCID: PMC11826836
DOI: 10.1177/17562864251313918

The impact of educational attainment on diagnostic and treatment delays in multiple sclerosis: a nationwide cohort study in Denmark

Elisabeth Framke et al. Ther Adv Neurol Disord. 2025.

. 2025 Feb 14:18:17562864251313918.

doi: 10.1177/17562864251313918. eCollection 2025.

Authors

Elisabeth Framke¹, Melinda Magyari^{2

3

4}; DMSG Study Group

Collaborators

DMSG Study Group:
Alex Heick⁵, Ana Isabel Figueira Jensen⁵, Anja Thormann⁵, Finn Sellebjerg⁶, Jeppe Romme Christensen⁵, Jesper Nørregaard⁵, Jette Lautrup Frederiksen⁶, Julie Richter Hansen⁵, Karen Ingrid Schreiber⁵, Morten Blinkenberg⁵, Per Soelberg Sørensen⁵, Rikke Marie Jensen⁵, Stephan Bramow⁷, Thor Chalmer⁵, Viktoria Papp Papp⁵, Melinda Magyari⁸, Nils Koch-Henriksen⁹, Morten Leif Munding Stilund¹⁰, Henrik Kahr Mathiesen¹¹, Henrik Boye Jensen¹², Egon Stenager¹³, Mai Bang Poulsen¹⁴, Michael Langemark¹⁴, Michael Broksgaard Jensen¹⁴, Nadia Mubder Issa¹⁴, Ásta Milthers Theódórsdóttir¹⁵, Helle Hvilsted Nielsen¹⁶, Manuel Demirovic¹⁵, Zsolt Laszlo Illés¹⁶, Homayoun Roshanisefat¹⁷, Nasrin Asgari¹⁸, Afzal Gardezi¹⁹, Matthias Kant¹⁹, Thor Petersen¹⁹, Tobias Sejbæk²⁰, Claudia Christensen²¹, Inga Urbonaviciute²², Ismael Barzinji²¹, Jakob Schäfer²¹, Camilla Mærsk-Møller²³, Caroline Winther Tørring²³, Kristina Bacher Svendsen²³, Peter Vestergaard Rasmussen²³, Georgi P Sirakov²⁴, Sivagini Prakash²⁴, Tsvetomir Asenov²⁴, Lars Kristian Storr²⁵, Lena Christina Roug²⁵, Monika Katarzyna Góra²⁵, Said Ashna²⁵

Affiliations

¹ The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital, Valdemar Hansens Vej 2, Entrance 8, Second Floor, DK-2600 Glostrup, Denmark.
² The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Glostrup, Denmark.
³ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital-Rigshospitalet, Glostrup, Denmark.
⁴ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
⁵ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark.
⁶ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
⁷ Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet ; Valdemar Hansens Vej 13, 2600 Glostrup, Denmark.
⁸ The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark; Danish Multiple Sclerosis Center, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 13, 2600 Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
⁹ The Danish Multiple Sclerosis Registry, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Valdemar Hansens Vej 2, 2600 Glostrup, Denmark; Department of Clinical Epidemiology, Clinical Institute, University of Aarhus, Olof Palmes Allé 43-45, 8200 Aarhus N.
¹⁰ Gødstrup Hospital, Department of Neurology, Physiotherapy and Occupational Therapy, Hospitalsparken 15, 7400 Herning, Denmark; NIDO | Centre for Research and Education, Gødstrup Hospital, Hospitalsparken 25, 7400 Herning, DenmarkArkadiusz Weglewski, MD, PhD, Department of Brain and Nerve Diseases, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.
¹¹ Department of Brain and Nerve Diseases, Copenhagen University Hospital, Herlev and Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark.
¹² Lillebælt Hospital, Department of Brain and Nerve Diseases, Sygehusvej 24, 6000 Kolding, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
¹³ Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
¹⁴ North Zealand Hospital, Copenhagen University Hospital, Department of Neurology, Dyrehavevej 29, 3400 Hillerød, Denmark.
¹⁵ Odense University Hospital, Department of Neurology, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
¹⁶ Odense University Hospital, Department of Neurology, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
¹⁷ Slagelse Hospital, Department of Neurology, Fælledvej 11, 4200 SlagelseMasoud Falah, MD, Slagelse Hospital, Department of Neurology, Fælledvej 11, 4200 Slagelse.
¹⁸ Slagelse Hospital, Department of Neurology, Fælledvej 11, 4200 Slagelse, Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
¹⁹ Hospital of Southern Jutland, Department of Neurology, University of Southern Denmark, Kresten Philipsens Vej 15, 6200 Aabenraa, Denmark.
²⁰ Southwest Jutland Hospital, Department of Neurology, University Hospital of Southern Denmark, 6700 Esbjerg, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
²¹ Aalborg University Hospital, Department of Neurology, Reberbanegade 15, 9100 Aalborg, Denmark.
²² Aalborg University Hospital, Department of Neurology, Reberbansgade 15, 9100 Aalborg, Denmark.
²³ Aarhus University Hospital, Department of Neurology, PJJ Boulevard 165, J504, 8200 Aarhus N, Denmark.
²⁴ Regionshospital Viborg, Hospitalsenhed Midt, Department of Neurology, Heibergs Allé 4, 8800 Viborg.
²⁵ Zealand University Hospital, Department of Neurology, Sygehusvej 10, 4000 Roskilde, Denmark.

PMID: 39958832
PMCID: PMC11826836
DOI: 10.1177/17562864251313918

Abstract

Background: In multiple sclerosis (MS), the educational gradient in diagnostic and disease-modifying treatment (DMT) delays is sparsely examined, and the results are mixed.

Objectives: Among patients with relapsing-remitting MS (RRMS), we aimed to examine the educational gradient in diagnostic delay and delay in the initiation of the first DMT.

Design: A nationwide cohort study.

Methods: We linked the Danish Multiple Sclerosis Registry with other nationwide registries. Diagnostic delay was evaluated in 4344 patients ⩾20 years at clinical onset with clinical onset from January 1, 2012, onwards, diagnosed by March 1, 2023. DMT delay was evaluated in 5402 patients ⩾20 years at MS diagnosis who were diagnosed from January 1, 2012, to March 1, 2022, with DMT initiation follow-up until March 1, 2023. The highest completed education before onset and diagnosis, respectively, was categorized using the International Standard Classification of Education (ISCED) into low (ISCED 0-2), medium (ISCED 3-4) and high (ISCED ⩾5) education. Endpoints were categorized according to their duration into four groups based on a population-specific quartile split. The highest quartile comprised long duration (⩾500 days (diagnostic delay) and ⩾76 days (DMT delay)). We calculated crude and adjusted odds ratios (OR) with 95% confidence intervals (CI).

Results: The mean age was 36.7 years (SD = 10.3, diagnostic delay population) and 39.2 years (SD = 10.9, DMT delay population). Most were female (67.4% and 68.3%) and of Danish origin (90.3% and 90.5%). Patients with low educational attainment did not have higher odds of diagnostic delay (OR = 1.05; 95% CI: 0.81-1.35) but had higher odds of DMT delay (OR = 1.48; 95% CI: 1.17-1.87) compared to patients with high educational attainment.

Conclusion: In adult patients with RRMS, low educational attainment was associated with higher odds of DMT delay but not diagnostic delay. Targeted interventions are needed to address educational disparities in healthcare access and treatment initiation.

Keywords: diagnostic delay; education; healthcare access; multiple sclerosis; treatment delay.

Plain language summary

Impact of educational attainment on diagnostic and treatment delays in multiple sclerosis Social determinants may influence health outcomes in multiple sclerosis. Education is an important social determinant established in early adulthood. Timely diagnosis and early treatment with disease-modifying treatment (DMT) is crucial in relapsing-remitting MS (RRMS). Among patients with RRMS, we hypothesized that low educational attainment would be associated with higher odds of diagnostic delay and delay in initiating the first DMT after diagnosis. We linked individual-level data on patients with RRMS from the Danish Multiple Sclerosis Registry with other nationwide registries from 2012 to 2023. Based on the International Standard Classification of Education, we assessed educational attainment as the highest completed education. Endpoints were categorized according to their duration into four groups based on a population-specific quartile split. We calculated multivariable-adjusted odds ratios with 95% confidence intervals. In adult patients with RRMS, low educational attainment was associated with higher odds of DMT delay but not diagnostic delay. Targeted interventions are needed to address educational disparities in healthcare access and treatment initiation.

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References

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The impact of educational attainment on diagnostic and treatment delays in multiple sclerosis: a nationwide cohort study in Denmark

Collaborators

Affiliations

The impact of educational attainment on diagnostic and treatment delays in multiple sclerosis: a nationwide cohort study in Denmark

Authors

Collaborators

Affiliations

Abstract

Plain language summary

References

LinkOut - more resources

Full Text Sources