Organization Determinants of Patient-Reported Experience of Integrated Care in Multiple Sclerosis: A Multilevel Analysis of Italian MS Clinical Centres

Abstract

Introduction
People with multiple sclerosis (MS) require coordinated care across multiple professionals, with potential risks of fragmentation and discontinuity. Within the activities of the Observatory on MS Policy at AISM, the Italian MS Foundation conducted two national surveys among people with MS (PwMS) and MS Clinical Centres (MSCCs). Patient experience of integrated care was measured using the Integrated Care Experience Scale for Multiple Sclerosis (ICES-MS), a validated MS-specific patient-reported experience measure [1]. Linking patient- and MSCC-level data enables assessment of how MS centre characteristics relate to patients’ experience of integrated care.

Objective
To assess the association between organizational characteristics of MSCCs and patient-reported experience of integrated care, measured using the ICES-MS, while accounting for individual patient characteristics and within-centre correlation.

Methods
Data were derived from two national cross-sectional surveys conducted by the Italian Multiple Sclerosis Foundation in 2026: one among Italian MS Clinical Centres and one among people with MS. The primary outcome was the total ICES-MS score, obtained by summing 8 items rated on a 0–3 Likert scale and rescaled to 0–100, with higher scores indicating integrated and person-centred care. Multilevel linear regression models with a centre-specific random intercept were fitted to account for patients nested within centres. Models were adjusted for centre-level and individual patient characteristics. The intraclass correlation coefficient (ICC) was estimated to quantify between-centre variability.

Results
Overall, 966 people with MS from 135 MSCCs were included. In the null model, the ICC was 0.046, indicating that 4.6% of ICES-MS variability was attributable to the centre level. The fully adjusted model was statistically significant (Wald χ²(20)=127.75, p<0.001). Compared with the reference area (South and Islands), ICES-MS scores were higher in PwMS treated by MSCC in Central Italy (β=8.77; 95% CI: 4.52 to 13.02), North-East Italy (β=9.66; 95% CI: 4.84 to 14.49), and North-West Italy (β=9.80; 95% CI: 5.40 to 14.21). Those treated in medium-sized centres showed higher scores than small centres (β=8.60; 95% CI: 3.28 to 13.93), whereas the association for large centres was not statistically significant (β=4.72; 95% CI: -0.91 to 10.34). PwMS treated in centres providing care based on a local integrated care pathway had higher scores than other centres (β=4.16; 95% CI: 0.10 to 8.22). Critical waiting times reported by clinicians were associated with lower scores (β=-5.11; 95% CI: -9.75 to -0.48). Increasing EDSS levels were associated with lower ICES-MS scores: β = -5.46 for the moderate group (95% CI: -9.11 to -1.82, p = 0.003) and β = -8.51 for the high group (95% CI: -13.87 to -3.15, p = 0.002). In the adjusted model, the ICC decreased to approximately 0.012.

Conclusions
Patient-reported experience of integrated and person-centred care showed limited but detectable variability across MS Clinical Centres. Higher ICES-MS scores were associated with medium-sized centres, a local integrated care pathway, and follow-up at centres located in Northern or Central Italy, whereas critical waiting times and higher disability levels were associated with lower scores. These findings suggest that both organizational/contextual characteristics of MS Clinical Centres and individual patient factors may influence patients’ experience of integrated care.