{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,11]],"date-time":"2026-08-11T16:38:58Z","timestamp":1786466338443,"version":"build-2736575974"},"reference-count":40,"publisher":"Elsevier BV","license":[{"start":{"date-parts":[[2025,10,1]],"date-time":"2025-10-01T00:00:00Z","timestamp":1759276800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/tdm\/userlicense\/1.0\/"},{"start":{"date-parts":[[2025,10,1]],"date-time":"2025-10-01T00:00:00Z","timestamp":1759276800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/legal\/tdmrep-license"},{"start":{"date-parts":[[2025,6,25]],"date-time":"2025-06-25T00:00:00Z","timestamp":1750809600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000024","name":"Canadian Institutes of Health Research","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000890","name":"National Multiple Sclerosis Society","doi-asserted-by":"publisher","award":["RG5063A4\/1\/ RFA-2103-37392"],"award-info":[{"award-number":["RG5063A4\/1\/ RFA-2103-37392"]}],"id":[{"id":"10.13039\/100000890","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["clinicalkey.com","clinicalkey.com.au","clinicalkey.es","clinicalkey.fr","clinicalkey.jp","msard-journal.com","elsevier.com","sciencedirect.com"],"crossmark-restriction":true},"short-container-title":["Multiple Sclerosis and Related Disorders"],"published-print":{"date-parts":[[2025,10]]},"DOI":"10.1016\/j.msard.2025.106595","type":"journal-article","created":{"date-parts":[[2025,6,25]],"date-time":"2025-06-25T11:09:12Z","timestamp":1750849752000},"page":"106595","update-policy":"https:\/\/doi.org\/10.1016\/elsevier_cm_policy","source":"Crossref","is-referenced-by-count":4,"special_numbering":"C","title":["Heterogeneity in health care pathways preceding the classical recognition of adult-onset multiple sclerosis: A multichannel state sequence analysis"],"prefix":"10.1016","volume":"102","author":[{"given":"Fardowsa L.A.","family":"Yusuf","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad Ehsanul","family":"Karim","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason M","family":"Sutherland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Feng","family":"Zhu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yinshan","family":"Zhao","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruth Ann","family":"Marrie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helen","family":"Tremlett","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"78","reference":[{"issue":"25","key":"10.1016\/j.msard.2025.106595_bib0001","doi-asserted-by":"crossref","first-page":"3107","DOI":"10.1002\/sim.3697","article-title":"Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples","volume":"28","author":"Austin","year":"2009","journal-title":"Stat. Med."},{"key":"10.1016\/j.msard.2025.106595_bib0002","unstructured":"BC Ministry of Health [creator] (2022): PharmaNet. V2. BC Ministry of Health [publisher]. Data Extract. Data Stewardship Committee (2022). http:\/\/www.popdata.bc.ca\/data."},{"key":"10.1016\/j.msard.2025.106595_bib0004","unstructured":"British Columbia Ministry of Health [creator] (2022): Medical Services Plan (MSP) payment information file. V2. Population data BC [publisher]. Data Extract. MOH (2022). http:\/\/www.popdata.bc.ca\/data."},{"key":"10.1016\/j.msard.2025.106595_bib0003","unstructured":"British Columbia Ministry of Health [creator] (2022): Consolidation file (MSP registration & premium billing). V2. Population data BC [publisher]. Data Extract. MOH (2022). http:\/\/www.popdata.bc.ca\/data."},{"key":"10.1016\/j.msard.2025.106595_bib0005","unstructured":"Canadian Institute for Health Information [creator] (2022): Discharge abstract database (Hospital Separations). V2. Population data BC [publisher]. Data Extract. MOH (2022). http:\/\/www.popdata.bc.ca\/data."},{"issue":"11","key":"10.1016\/j.msard.2025.106595_bib0006","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1016\/0895-4356(94)90129-5","article-title":"Validation of a combined comorbidity index","volume":"47","author":"Charlson","year":"1994","journal-title":"J. Clin. Epidemiol."},{"issue":"4","key":"10.1016\/j.msard.2025.106595_bib0007","doi-asserted-by":"crossref","first-page":"616","DOI":"10.1002\/ana.24769","article-title":"Preclinical disease activity in multiple sclerosis: a prospective study of cognitive performance prior to first symptom","volume":"80","author":"Cortese","year":"2016","journal-title":"Ann. Neurol."},{"issue":"6","key":"10.1016\/j.msard.2025.106595_bib0008","doi-asserted-by":"crossref","first-page":"1162","DOI":"10.1002\/ana.25247","article-title":"Prodromal symptoms of multiple sclerosis in primary care","volume":"83","author":"Disanto","year":"2018","journal-title":"Ann. Neurol."},{"key":"10.1016\/j.msard.2025.106595_bib0009","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.jvb.2015.04.005","article-title":"Optimal matching analysis in career research: a review and some best-practice recommendations","volume":"90","author":"Dlouhy","year":"2015","journal-title":"J. Vocat. Behav."},{"issue":"4","key":"10.1016\/j.msard.2025.106595_bib0010","article-title":"Treatment with disease-modifying drugs for people with a first clinical attack suggestive of multiple sclerosis","volume":"4","author":"Filippini","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"issue":"4","key":"10.1016\/j.msard.2025.106595_bib0011","doi-asserted-by":"crossref","first-page":"1","DOI":"10.18637\/jss.v040.i04","article-title":"Analyzing and visualizing state sequences in R with TraMineR","volume":"40","author":"Gabadinho","year":"2011","journal-title":"J. Stat. Softw."},{"key":"10.1016\/j.msard.2025.106595_bib0012","unstructured":"Government of Canada, 2023. Forward sortation area-definition.https:\/\/ised-isde.canada.ca\/site\/office-superintendent-bankruptcy\/en\/statistics-and-research\/forward-sortation-area-fsa-and-north-american-industry-classification-naics-reports\/forward-sortation-area-definition (accessed 2 March 2023)."},{"issue":"10","key":"10.1016\/j.msard.2025.106595_bib0013","doi-asserted-by":"crossref","first-page":"1464","DOI":"10.1002\/mds.27802","article-title":"Update of the MDS research criteria for prodromal Parkinson\u2019s disease","volume":"34","author":"Heinzel","year":"2019","journal-title":"Mov. Disord."},{"issue":"6","key":"10.1016\/j.msard.2025.106595_bib0014","doi-asserted-by":"crossref","DOI":"10.1037\/0033-2909.83.6.1072","article-title":"A general statistical framework for assessing categorical clustering in free recall","volume":"83","author":"Hubert","year":"1976","journal-title":"Psychological bulletin."},{"key":"10.1016\/j.msard.2025.106595_bib0015","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.jns.2010.02.007","article-title":"Factors associated with delay to medical recognition in two Canadian multiple sclerosis cohorts","volume":"292","author":"Kingwell","year":"2010","journal-title":"J. Neurol. Sci."},{"issue":"5","key":"10.1016\/j.msard.2025.106595_bib0016","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1007\/s00415-008-0778-x","article-title":"Clinical characteristics of patients with late-onset multiple sclerosis","volume":"255","author":"Kis","year":"2008","journal-title":"J. Neurol."},{"issue":"1","key":"10.1016\/j.msard.2025.106595_bib0017","doi-asserted-by":"crossref","first-page":"78","DOI":"10.1016\/S1474-4422(22)00289-7","article-title":"Multiple sclerosis progression: time for a new mechanism-driven framework","volume":"22","author":"Kuhlmann","year":"2023","journal-title":"Lancet Neurol."},{"issue":"11","key":"10.1016\/j.msard.2025.106595_bib0018","doi-asserted-by":"crossref","first-page":"1444","DOI":"10.1212\/WNL.33.11.1444","article-title":"Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS)","volume":"33","author":"Kurtzke","year":"1983","journal-title":"Neurology"},{"issue":"3","key":"10.1016\/j.msard.2025.106595_bib0019","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1177\/0049124110362526","article-title":"Setting cost in optimal matching to uncover contemporaneous socio-temporal patterns","volume":"38","author":"Lesnard","year":"2010","journal-title":"Sociol. Methods Res."},{"issue":"6","key":"10.1016\/j.msard.2025.106595_bib0020","first-page":"434","article-title":"How long are Canadians waiting to access specialty care?: retrospective study from a primary care perspective","volume":"66","author":"Liddy","year":"2020","journal-title":"Can. Fam. Physician"},{"issue":"06","key":"10.1016\/j.msard.2025.106595_bib0021","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1017\/S0317167100015961","article-title":"The incidence and prevalence of multiple sclerosis in Nova Scotia, Canada","volume":"40","author":"Marrie","year":"2013","journal-title":"Can. J. Neurol. Sci."},{"issue":"3","key":"10.1016\/j.msard.2025.106595_bib0022","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1017\/S2045796017000579","article-title":"Rising incidence of psychiatric disorders before diagnosis of immune-mediated inflammatory disease","volume":"28","author":"Marrie","year":"2019","journal-title":"Epidemiol. Psychiatr. Sci."},{"issue":"1","key":"10.1016\/j.msard.2025.106595_bib0023","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1186\/s12913-021-07450-9","article-title":"Exploring social inequalities in healthcare trajectories following diagnosis of diabetes: a state sequence analysis of linked survey and administrative data","volume":"22","author":"McKay","year":"2022","journal-title":"BMC Health Serv. Res."},{"issue":"2","key":"10.1016\/j.msard.2025.106595_bib0024","doi-asserted-by":"crossref","first-page":"191","DOI":"10.14301\/llcs.v8i2.415","article-title":"Longitudinal methods for life course research: a comparison of sequence analysis, latent class growth models, and multi-state event history models for studying partnership transitions","volume":"8","author":"Mikolai","year":"2017","journal-title":"Longitud. Life Course Stud."},{"issue":"8","key":"10.1016\/j.msard.2025.106595_bib0025","doi-asserted-by":"crossref","first-page":"871","DOI":"10.1136\/jnnp-2015-311890","article-title":"The prediagnostic phase of Parkinson\u2019s disease","volume":"87","author":"Noyce","year":"2016","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"issue":"6","key":"10.1016\/j.msard.2025.106595_bib0026","doi-asserted-by":"crossref","first-page":"1651","DOI":"10.1177\/0962280218772068","article-title":"Use of state sequence analysis for care pathway analysis: the example of multiple sclerosis","volume":"28","author":"Roux","year":"2019","journal-title":"Stat. Methods Med. Res."},{"key":"10.1016\/j.msard.2025.106595_bib0027","series-title":"Multiple Imputation for Nonresponse in Surveys","author":"Rubin","year":"1987"},{"key":"10.1016\/j.msard.2025.106595_bib0028","unstructured":"Statistics Canada. 8. Health system indicators (Canadian Institute for Health Information \u2013 CIHI). https:\/\/www150.statcan.gc.ca\/n1\/pub\/82-221-x\/2013001\/quality-qualite\/qua8-eng.htm (accessed 2 March 2023)."},{"issue":"8","key":"10.1016\/j.msard.2025.106595_bib0029","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0255992","article-title":"Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada","volume":"16","author":"Stephenson","year":"2021","journal-title":"PLoS One"},{"issue":"2","key":"10.1016\/j.msard.2025.106595_bib0030","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1111\/rssa.12125","article-title":"What matters in differences between life trajectories: a comparative review of sequence dissimilarity measures","volume":"179","author":"Studer","year":"2016","journal-title":"J. R. Stat. Soc. Ser. A Stat. Soc."},{"issue":"16","key":"10.1016\/j.msard.2025.106595_bib0031","doi-asserted-by":"crossref","first-page":"1668","DOI":"10.1212\/WNL.0000000000004508","article-title":"Comorbidity in multiple sclerosis is associated with diagnostic delays and increased mortality","volume":"89","author":"Thormann","year":"2017","journal-title":"Neurology"},{"issue":"3","key":"10.1016\/j.msard.2025.106595_bib0032","first-page":"1","article-title":"Mice: multivariate imputation by chained equations in R","volume":"45","author":"van Buuren","year":"2011","journal-title":"J. Stat. Softw."},{"issue":"1","key":"10.1016\/j.msard.2025.106595_bib0033","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12913-020-5030-0","article-title":"Healthcare utilization after a first hospitalization for COPD: a new approach of state sequence analysis based on the \u201c6W\u201d multidimensional model of care trajectories","volume":"20","author":"Vanasse","year":"2020","journal-title":"BMC Health Serv. Res."},{"issue":"1","key":"10.1016\/j.msard.2025.106595_bib0034","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/s41537-022-00256-6","article-title":"Multidimensional analysis of adult patients\u2019 care trajectories before a first diagnosis of schizophrenia","volume":"8","author":"Vanasse","year":"2022","journal-title":"Schizophrenia"},{"issue":"14","key":"10.1016\/j.msard.2025.106595_bib0035","doi-asserted-by":"crossref","first-page":"1816","DOI":"10.1177\/1352458520970841","article-title":"Rising prevalence of multiple sclerosis worldwide: insights from the Atlas of MS, third edition","volume":"26","author":"Walton","year":"2020","journal-title":"Mult. Scler."},{"issue":"4","key":"10.1016\/j.msard.2025.106595_bib0036","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1002\/sim.4067","article-title":"Multiple imputation using chained equations: issues and guidance for practice","volume":"30","author":"White","year":"2011","journal-title":"Stat. Med."},{"issue":"6","key":"10.1016\/j.msard.2025.106595_bib0037","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1016\/S1474-4422(17)30076-5","article-title":"Health-care use before a first demyelinating event suggestive of a multiple sclerosis prodrome: a matched cohort study","volume":"16","author":"Wijnands","year":"2017","journal-title":"Lancet Neurol."},{"issue":"8","key":"10.1016\/j.msard.2025.106595_bib0038","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.1177\/1352458518783662","article-title":"Five years before multiple sclerosis onset: phenotyping the prodrome","volume":"25","author":"Wijnands","year":"2019","journal-title":"Mult. Scler. J."},{"issue":"2","key":"10.1016\/j.msard.2025.106595_bib0040","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1177\/1352458520908163","article-title":"Fatigue, sleep disorders, anaemia and pain in the multiple sclerosis prodrome","volume":"27","author":"Yusuf","year":"2021","journal-title":"Mult. Scler. J."},{"key":"10.1016\/j.msard.2025.106595_bib0039","doi-asserted-by":"crossref","first-page":"2418","DOI":"10.3389\/fneur.2022.1017492","article-title":"Sex and age differences in the Multiple Sclerosis prodrome","volume":"13","author":"Yusuf","year":"2022","journal-title":"Front. Neurol."}],"container-title":["Multiple Sclerosis and Related Disorders"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S2211034825003372?httpAccept=text\/xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S2211034825003372?httpAccept=text\/plain","content-type":"text\/plain","content-version":"vor","intended-application":"text-mining"}],"deposited":{"date-parts":[[2026,5,29]],"date-time":"2026-05-29T07:21:54Z","timestamp":1780039314000},"score":1,"resource":{"primary":{"URL":"https:\/\/linkinghub.elsevier.com\/retrieve\/pii\/S2211034825003372"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10]]},"references-count":40,"alternative-id":["S2211034825003372"],"URL":"https:\/\/doi.org\/10.1016\/j.msard.2025.106595","relation":{},"ISSN":["2211-0348"],"issn-type":[{"value":"2211-0348","type":"print"}],"subject":[],"published":{"date-parts":[[2025,10]]},"assertion":[{"value":"Elsevier","name":"publisher","label":"This article is maintained by"},{"value":"Heterogeneity in health care pathways preceding the classical recognition of adult-onset multiple sclerosis: A multichannel state sequence analysis","name":"articletitle","label":"Article Title"},{"value":"Multiple Sclerosis and Related Disorders","name":"journaltitle","label":"Journal Title"},{"value":"https:\/\/doi.org\/10.1016\/j.msard.2025.106595","name":"articlelink","label":"CrossRef DOI link to publisher maintained version"},{"value":"article","name":"content_type","label":"Content Type"},{"value":"\u00a9 2025 The Author(s). Published by Elsevier B.V.","name":"copyright","label":"Copyright"}],"article-number":"106595"}}