The societal costs of multiple sclerosis in Lebanon: a cross-sectional study

Figures & data

Table 1. Demographic characteristics of patients, disease information, and employment.

	Sample	Mild MS, EDSS 0–3	Moderate MS, EDSS 4–6.5	Severe MS, EDSS 7–9
N	210	116 (55%)	67 (32%)	27 (13%)
Mean age (SD)	43.3 (12.9)	38.1 (11)	47.7 (11.9)	54.9 (11.2)
Gender (% Female)	65.7%	64.7%	67.2%	66.7%
Educational level (%)
Primary	21%	10.3%	32.8%	37%
Secondary	25.2%	25%	31.3%	11.1%
Vocational diploma	20%	24.1%	11.9%	22.2%
University	33.8%	40.5%	23.9%	29.6%
Marital status (%)
Single	25.7%	31%	17.9%	22.2%
Married	66.2%	62.9%	73.1%	63%
Other	8.1%	6%	9%	14.8%
Mean number of children (SD)	1.8 (1.7)	1.4 (1.5)	2.3 (2.1)	2.1(1.5)
Main family provider (%)	25.2%	26.7%	23.9%	22.2%
Disease information
Mean age at disease onset, years (SD)	33.4 (11.3)	29.8 (9.6)	37.6 (11.6)	38.8 (12.1)
Mean age at first symptoms, years (SD)	31.2 (10.5)	28.8 (9.9)	34.8 (11.3)	32.4 (8.6)
Mean EDSS (SD)	3.1 (2.7)	1 (1.1)	4.8 (0.8)	7.9 (0.8)
Relapses (%)	4.3%	4.3%	6%	0%
DMTs use (%)	86.7%	94.0%	91.0%	44.4%
Employment
Patients of working age (%)	95.2%	97.4%	95.50%	85.20%
Employed or self-employed (%)	42.4%	58.6%	23.9%	18.5%
Unemployed due to MS (%)	12.9%	5.2%	14.9%	40.7%
Current situation not working (%)	Homemaker (36.7%), Student (3.8%), Retired (6.7%), Unemployed (10.5%)	-	-	-
Short-term absence (past 3 months) (%)	15.7%	14.7%	25%	0%
Long-term absence (3–12 months) (%)	2.2%	2.9%	0.0%	0.0%
Mean MS effect on productivity (SD) (past 7 days)	1.8 (2.6)	1.4 (2.2)	2.9 (3.2)	3.2 (4.4)

MS: multiple sclerosis; SD: standard deviation; EDSS: Expanded Disability Status Scale; DMTs: disease-modifying treatments.

Figure 1. Type of DMTs used (n = 182).

DMTs: disease-modifying treatments.

Table 2. Resource utilization, health care and community services among all patients in the total sample and by EDSS level.

	Sample(n = 210)		Mild MS, EDSS 0–3 (n = 116)		Moderate MS, EDSS 4–6.5 (n = 67)		Severe MS, EDSS 7–9 (n = 27)
	% Of users	Mean (SD) use per patient	% Of users	Mean (SD) use per patient	% Of users	Mean (SD) use per patient	% Of users	Mean (SD) use per patient
Hospitalization (3 months)
Inpatient care (overnight stay)	4.8%	0.14 (0.7)	4.3%	0.14 (0.8)	7.5%	0.19 (0.8)	0	0.0
Outpatient care (days)	8.1%	0.10 (0.4)	9.5%	0.11 (0.4)	7.5%	0.09 (0.3)	3.7%	0.04 (0.2)
Rehabilitation (times)	7.1%	0.94 (4.3)	4.3%	0.69 (4.1)	13.4%	1.73 (5.1)	3.7%	0.04 (0.2)
Healthcare consultations^1 (visits over 3-month period)	93.3%		92.2%		94.0%		96.3%
Neurologist	86.7%	1 (0.6)	87.1%	0.97 (0.5)	85.1%	1.09 (0.8)	88.9%	0.93 (0.4)
Internist	2.4%	0.04 (0.3)	2.6%	0.04 (0.3)	1.5%	0.04 (0.4)	3.7%	0.04 (0.2)
Urologist	3.3%	0.05 (0.3)	1.7%	0.02 (0.1)	6.0%	0.10 (0.5)	3.7%	0.04 (0.2)
Ophthalmologist	8.6%	0.10 (0.4)	13.8%	0.16 (0.5)	1.5%	0.01 (0.1)	3.7%	0.04 (0.2)
Psychologist or Counselor	1.4%	0.11 (1)	2.6%	0.20 (1.3)	0%	0.0	0%	0.0
General practitioner	4.8%	0.06 (0.3)	2.6%	0.03 (0.2)	7.5%	0.12 (0.5)	7.4%	0.07 (0.3)
Dietitian	1.9%	0.02 (0.18)	3.4%	0.04 (0.24)	0%	0.0	0%	0.0
Speech therapist	0%	0.0	0.0	0.0	0%	0.0	0%	0.0
Physical therapist	8.1%	1.56 (6.6)	3.4%	0.42 (2.8)	10.4%	1.82 (6.3)	22.2%	5.78 (13.7)
Other healthcare specialists	27.6%	0.47 (0.9)	28.4%	0.46 (0.9)	29.9%	0.60 (1.1)	18.5%	0.19 (0.4)
Medication (over 3- month period)
DMTs	86.7%		94%		91%		44.4%
Relapse treatments	3.8%		3.40%		6%		0%
Other prescription and non-prescription drugs (pills)	99%		99.1%		98.5%		100%
Pain	41.4%	36.38 (57.1)	19.8%	11.52 (31)	62.7%	58.93 (65.3)	81.5%	87.22 (66)
Urologic	11.0%	4.92 (15.4)	5.2%	2.70 (12.5)	14.9%	5.82 (15)	25.9%	12.22 (23.9)
Fatigue	1.9%	1.14 (8.7)	1.7%	1.03 (8.8)	1.5%	0.90 (7.3)	3.7%	2.22 (11.5)
Depression	34.3%	13.95 (23.8)	24.1%	7.92 (15.4)	44.8%	20.60 (30)	51.9%	23.33 (29.2)
Vitamin E	0.5%	0.14 (2.1)	0.0%	–	1.5%	0.45 (3.7)	0.0%	–
Vitamin B	6.7%	2.04 (8.8)	5.2%	1.38 (7.3)	9.0%	3.12 (11.3)	7.4%	2.22 (8)
Vitamin D	96.7%	7.19 (6.8)	97.4%	6.37 (5.8)	97.0%	7.88 (7.2)	92.6%	8.96 (8.8)
Omega 3	8.6%	2.26 (8.2)	6.0%	1.23 (5.7)	10.4%	3.16 (10.4)	14.8%	4.44 (10.9)
Selenium	1%	0.29 (2.9)	0.0%	–	1.5%	0.45 (3.7)	3.7%	1.11 (5.8)
Other drugs	48.6%	36.76 (65.5)	37.1%	19.14 (32)	52.2%	45.58 (65.8)	88.9%	90.59 (119.9)
Tests (over 3-month period)	63.3%		66.4%		61.2%		55.6%
MRI (brain or spine)	36.2%		41.4%		34.4%		18.5%
CT Scan (computed tomography)	0.5%		0.0%		1.5%		0.0%
Spinal tap (lumbar puncture, cerebrospinal fluid (CSF) analysis)	0.0%		0.0%		0.0%		0.0%
Visual evoked potential	2.9%		4.3%		1.5%		0.0%
Ultrasound Heart (echocardiography, ultrasound cardiogram, UCG)	1.0%		1.7%		0.0%		0.0%
Ultrasound Bladder	1.0%		0.9%		1.5%		0.0%
Electrocardiogram	2.4%		3.4%		1.5%		0.0%
Blood tests	58.1%		59.5%		58.2%		51.9%
Investments and equipment^1 (over 12- month period)	19.5%		0.9%		25.4%		85.2%
Stair lift elevator	0.5%		0.0%		0.0%		3.7%
Walking aids	14.8%		0.0%		23.9%		55.6%
Wheelchair	5.2%		0.0%		0.0%		40.7%
Electric wheelchair	1.0%		0.0%		0.0%		7.4%
Special equipment	1.9%		0.9%		0.0%		11.1%
Other modifications	1.9%		0.0%		1.5%		11.1%
Assistance (over 3-month period)	19.5%		0.9%		26.9%		81.5%
Formal care (professional care) (days)	7.1%	5.60 (21.3)	0.9%	0.78 (8.4)	9.0%	6.79 (23.8)	26.6%	23.33 (38.4)
Nurse	1.4%		0.0%		1.5%		7.4%
Housekeeper	5.7%		0.9%		7.5%		22.2%
Informal care (days)	15.2%	11.23 (28.4)	0.0%	0.0	22.4%	15.54 (32.1)	63%	48.81 (42.3)
Transportation (trips)	100%	1.58 (1)	100%	1.60 (1)	100%	1.63 (1.1)	100%	1.33 (0.6)
Financial Aid	15.2%		8.6%		22.4%		25.9%

MS: multiple sclerosis; EDSS: Expanded Disability Status Scale; SD: standard deviation; DMTs: disease-modifying treatments; MRI: magnetic resonance imaging

¹ Speech therapists under healthcare consultations and bed-lift ramps rails within investments and equipment were not used by any patient.

Table 3. Total mean (SD) annual costs per patient in 2021 LBP for Scenarios 1 and 2 of the sensitivity analysis, excluding DMTs, by EDSS classification groups.

	Total sample(n = 210)		Mild MS, EDSS 0–3 (n = 116)		Moderate MS, EDSS 4–6.5 (n = 67)		Severe MS, EDSS 7–9 (n = 27)
	S1	S2	S1	S2	S1	S2	S1	S2
Hospitalization	1,334,136 (4,854,197)	3,108,660 (9,539,195)	1,599,701 (5,847,678)	3,428,757 (11,184,605)	1,372,506 (3,767,234)	3,727,647 (8,115,278)	97,972 (481,849)	197,425 (860,372)
Healthcare consultations	2,081,810 (2,731,365)	3,490,381 (5,409,628)	1,636,379 (1,486,359)	2,624,207 (2,869,269)	2,308,657 (2,756,434)	3,867,284 (5,344,479)	3,432,593 (5,291,349)	6,276,444 (10,702,472)
Medication	2,300,131 (448,488)	7,552,309 (9,129,422)	609,530 (950,395)	4,167,364 (3,825,999)	2,840,715 (322,401)	9,528,064 (7,264,128)	8,222,005 (3,150,230)	17,192,235 (17,708,769)
Tests	2,724,438 (3,209,031)	5,419,505 (6,278,734)	3,025,793 (3,228,693)	6,040,586 (6,308,324)	2,718,149 (3,370,256)	5,376,060 (6,616,245)	1,445,333 (2,394,411)	2,858,963 (4,607,092)
Total direct medical costs	8,440,514 (9,368,364)	19,570,855 (17,140,079)	6,871,404 (7,391,306)	16,260,914 (15,112,718)	9,240,027 (7,278,921)	22,499,055 (16,953,068)	13,197,902 (17,124,160)	26,525,067 (22,373,782)
Investments and equipment	428,302 (2,503,833)	791,481 (4,729,796)	5,641 (60,755)	10,668 (114,899)	58,035 (121,082)	82,927 (184,342)	3,162,911 (6,436,155)	5,904,352 (12,186,995)
Formal care	1,199,652 (5,011,324)	2,153,358 (9,286,948)	68,966 (742,781)	68,966 (742,781)	1,567,361 (6,159,296)	2,867,104 (11,609,740)	5,144,955 (8,995,261)	9,337,374 (16,565,476)
Informal care	952,235 (2,822,152)	2,475,516 (7,336,722)	0.00	0.00	840,668 (2,418,781)	2,185,476 (6,288,081)	5,320,169 (5,028,039)	13,830,792 (13,071,0344)
Transportation	753,305 (979,221)	2,632,686 (3,345,185)	755,863 (1,122,739)	2,564,897 (3,715,032)	719,070 (646,310)	2,588,597 (2,383,378)	827,272 (1,031,171)	3,033,333 (3,780,957)
Total non-medical costs	3,333,495 (7,258,192)	8,053,040 (14,691,380)	830,469 (1,327,074)	2,644,530 (3,765,566)	3,185,134 (6,416,084)	7,724,104 (12,707,344)	14,455,387 (12,438,884)	32,105,851 (23,039,085)
Short-term absence	151,999 (959,964)	395,201 (2,495,920)	110,783 (424,721)	288,038 (1,104,279)	284,612 (1,640,239)	739,996 (4,171,042)	0.00	0.00
Long-term absence	25,662 (344,328)	66,722 (895,259)	46,458 (463,141)	120,790 (1,204,172)	0.00	0.00	0.00	0.00
Early retirement	14,852,571 (13,662,222)	38,616,686 (35,521,778)	11,085,517 (13,489,991)	28,822,345 (35,073,976)	19,601,194 (12,425,222)	50,963,104 (32,305,576)	19,253,333 (12,731,200)	50,058,667 (33,101,119)
Total indirect cost	15,030,233 (13,506,553)	39,078,609 (35,117,035)	11,242,758 (13,376,194)	29,231,173 (34,778,103)	19,885,806 (12,067,857)	51,703,100 (31,376,425)	19,253,333 (12,731,200)	50,058,667 (33,101,119)
Total costs 2021	26,804,242 (19,091,652)	66,702,504 (44,529,459)	18,944,631 (16,081,616)	48,136,618 (39,977,651)	32,310,967 (13,867,516)	81,926,259 (34,681,901)	46,906,622 (22,901,904)	108,689,584 (43,024,058)

LBP: Lebanese pound; MS: multiple sclerosis; EDSS: Expanded Disability Status Scale; SD: standard deviation; S1: Scenario 1 (before subsidies were lifted); S2: Scenario 2 (after subsidies were lifted); Medication: relapse treatments and other prescription and non-prescription drugs; MRI: Magnetic resonance imaging

Figure 2. Total mean annual costs per patient converted to year 2021 PPP US$ and presented by EDSS classification groups.

PPP: Purchasing Power Parity; MS: multiple sclerosis; EDSS: Expanded Disability Status Scale; DMTs: disease-modifying treatments, Medication: relapse treatments and other prescription and non-prescription drugs

Table 4. Total mean annual costs per patient for scenario 2, including DMTs, converted to year 2021 PPP US$ and presented by EDSS classification groups.

	Total sample (n = 210)		Mild MS, EDSS 0–3 (n = 116)		Moderate MS, EDSS 4–6.5 (n = 67)		Severe MS, EDSS 7–9 (n = 27)		P-value	Partial eta squared
	Mean (SD)	95% CI	Mean (SD)	95% CI	Mean (SD)	95% CI	Mean (SD)	95% CI
Hospitalization	1,051 (3,225)	612–1,490	1,159 (3,781)	464–1,854	1,260 (2,743)	591–1,929	67(291)	(48)-182	0.058	0.014
Healthcare consultations	1,180 (1,829)	931–1,429	887 (970)	709–1,066	1,307 (1,807)	867–1,748	2,122 (3,618)	691–3,553	0.288	0.05
Medication	2,553 (3,086)	2,133–2,973	1,409 (1,293)	1,171–1,647	3,221 (2,456)	2,622–3,820	5,812 (5,986)	3,444–8,180	<0.001*	0.235
DMTs	10,569 (8,368)	9,430–11,707	13,706 (7,497)	12,328–15,085	8,430 (8,022)	6,474–10,387	2,394 (5,087)	381–4,406	<0.001*	0.222
Tests	1,832 (2,123)	1,543–2,121	2,042 (2,133)	1,650–2,434	1,817 (2,237)	1,272–2,363	966 (1,557)	350–1,583	0.105	0.027
Total direct medical costs	17,185 (9,288)	15,921–18,448	19,203 (8,157)	17,703–20,704	16,036 (10,330)	13,516–18,556	11,316 (8,451)	8,017–14,704	<0.001*	0.082
Investments and equipment	728 (3,139)	301–1,155	23 (251)	(23)-69	969 (3,925)	12–1,927	3,157 (5,600)	941–5,372	<0.001*	0.107
Formal care	837 (2,480)	499–1,174	0	NA	739 (2,126)	220–1,257	4,676 (4,419)	2,928–6,424	<0.001*	0.373
Informal care	268 (1,599)	50–485	4 (39)	(4)-11	28 (62)	13–43	1,996 (4,120)	366–3,626	<0.001*	0.173
Transportation	890 (1,131)	736–1,044	867 (1,256)	636–1,098	875 (806)	679–1,072	1,025 (1,278)	520–1,531	0.801	0.002
Total non-medical costs	2,722 (4,966)	2,047–3,398	894 (1,273)	660–1,128	2,611 (4,296)	1,563–3,659	10,853 (7,788)	7,772–13,934	<0.001*	0.422
Total indirect costs	13,211 (11,871)	11,596–14,826	9,882 (11,757)	7,719–12,044	17,478 (10,607)	14,891–20,066	16,922 (11,190)	12,496–21,349	<0.001*	0.098
Total costs	33,117 (14,253)	31,178–35,056	29,979 (14,006)	27,403–32,555	36,125 (13,400)	32,857–39,394	39,136 (14,307)	33,477–44,796	0.001*	0.064

PPP: Purchasing Power Parity; MS: multiple sclerosis; EDSS: Expanded Disability Status Scale; SD: standard deviation; 95% CI: 95% confidence interval; DMTs: disease-modifying treatments; Medication: relapse treatments and other prescription and non-prescription drugs; NA: not applicable

*Difference is statistically significant (p < 0.05). EDSS: expanded disability status scale; MS: multiple sclerosis; SD: standard deviation.

Partial eta squared (ɳ2; effect size) values of 0.01, 0.06, and 0.14 indicate small, medium, and large effects, respectively.