Research Article: High rates of health care utilization in pediatric multiple sclerosis: A Canadian population-based study

Date Published: June 11, 2019

Publisher: Public Library of Science

Author(s): Ruth Ann Marrie, Julia O’Mahony, Colleen J. Maxwell, Vicki Ling, E. Ann Yeh, Douglas L. Arnold, Amit Bar-Or, Brenda Banwell, David Meyre.


We aimed to compare health care utilization of children with pediatric-onset multiple sclerosis to that of age, sex and geographically-matched children without multiple sclerosis. Using population-based administrative data from Ontario, Canada for the period 2003–2014, we applied a validated case definition to identify persons aged ≤18 years with multiple sclerosis. We identified up to 5 children without multiple sclerosis matched on sex, age, and region of residence. In each cohort, we determined annual rates of any hospitalization and physician services use. Using general linear models we compared utilization rates adjusting for age, sex, region, socioeconomic status and year. Subsequently, we limited the analysis to incident cases of multiple sclerosis and their matches, and compared rates of utilization in the year of multiple sclerosis diagnosis, and the three years thereafter. We identified 659 youth with multiple sclerosis (428 incident cases), and 3,294 matched controls. Two-thirds of both cohorts were female. After adjustment for sociodemographic factors and year, the multiple sclerosis cohort was more likely to be hospitalized than the matched cohort (odds ratio 15.2; 95%CI: 12.0, 19.1), and had higher rates of ambulatory physician visits (rate ratio 4.58; 95%CI: 4.26, 4.92). The odds of hospitalization (odds ratio 40.1; 95%CI: 27.1, 59.5) and physician visits (rate ratio 5.14; 95%CI: 4.63, 5.71) were markedly elevated in the year of MS diagnosis, declining thereafter but remaining elevated versus the matched cohort. Children with multiple sclerosis have substantially elevated rates of health care utilization as compared to matched children without multiple sclerosis, over calendar time and throughout the early disease course.

Partial Text

Multiple sclerosis (MS) is a disease of the central nervous system which most commonly presents in adulthood. Affected adults have higher rates of health care utilization as compared to age and sex-matched adults without MS,[1, 2] but utilization in this population has changed over time, most notably due to a decrease in hospitalization rates.[1, 3] In about 5% of individuals with MS, the initial presentation is in childhood or adolescence. However, relatively little is known about health care utilization in the pediatric MS population. Prior studies have involved small cohorts, or have not been population-based.[4, 5]

We identified 659 children and adolescents living with MS during the study period. Of these, all but one had five matches for a total of 3,294 controls; thus the total sample for this study included 3,953 youth. The cohorts were well-matched (Table 1). Two-thirds of the cohorts were female. Most participants lived in urban areas. Health care utilization in the year before the index date (first demyelinating disease claim) was higher in the MS cohort.

In this population-based cohort study, health care utilization was higher in the pediatric MS population than in a matched population without MS, after accounting for predisposing (age, sex) and enabling factors (region and SES). Male youth had a lower likelihood of hospitalization and lower rates of physician visits than female youth. Older age was associated with an increased likelihood of hospitalization and higher rates of physician visits. In the three years after diagnosis, rural residence was associated with lower health care utilization, suggesting that access to care factors such as distance and transportation costs influence use. Such disparities could be differentially affected by severity of MS, but we lacked the clinical information to evaluate this. The increased use of ambulatory physician services by the MS cohort extended to primary care and specialty care. Consistent with the increased risk of mental health and behavioral concerns in MS,[13] and frequent involvement of the eyes (optic neuritis), and potentially physically disabling relapses, visits to psychiatry, ophthalmology and physiatry were more frequent. This highlights the importance of multidisciplinary care in pediatric MS. However, our findings do not indicate whether the needs of children with MS are being fully met.