Medical Decision Making in Multiple System Atrophy

Study Overview
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Brief Summary
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The goal of this clinical study is to evaluate the effects of a personalized symptomatic treatment plan integrated with monthly telemedicine and mobile palliative care interventions on a population of individuals diagnosed with Multiple System Atrophy (MSA) and their informal caregivers. The aim is to improve the quality of life of MSA patients and their caregivers, as well as provide them with better support during the disease progression. After a baseline visit, all 46 patients will receive a personalized therapeutic plan (including medical treatment, physiotherapy, logotherapy and occupational therapy excercises and psychological support) and contact with social workers and a palliative care team. They willl then be re-evaluated at 6-,12-, 18- month visits. Semi-structured online interviews at baseline and 12 month visit will collect patients' individual healthcare preferences, which will be taken into account in the preparation of the individual therapeutic plan. Twenty-three patients will be randomized to receive monthly telemedicine visits. Assessment of patients´satisfaction with the therapeutic plan, with the palliative interventions (when they occurred) and the telemedicine visits will be carried over the 18 month period. Forty-six informal caregivers will be invited to participate with semi-structured online interviews and assessment of their QoL and caregivers' burden.

Detailed Description
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This is a monocentric, 18-months, randomized, rater-blinded study to evaluate the influence of a multidisciplinary, personalized symptomatic treatment plan with integrated mobile palliative care and telemedicine on the baseline to 18-months change in the QoL of individuals with MSA compared to a sex-, age- and disease-duration matched historical European MSA cohort, whose data is stored at the Medical University of Innsbruck. We plan to recruit 46 individuals with MSA fulfilling all the inclusionand none of the exclusion criteria. Upon collection of written informed consent, the recruited individuals will be instructed to complete a falls protocol referred to the month preceding the baseline visit, as well as a blood pressure (BP), bladder diary for up to 72 hours prior to the baseline visit. They will subsequently undergo a baseline examination including a comprehensive clinical, psychological and neuro-rehabilitation assessment, as well as an online semi-structured interview aimed at pinpointing the individual therapeutic needs and healthcare preferences. In case additional examinations are needed, these will be carried out on the same day of the baseline visit or, if not possible for individual or appointment reasons, at the earliest possible time point within the given timeframe as outlined in the visit schedule. Upon completion of the baseline visit and examinations, the individualized therapeutic plan, including mobile palliative care offer (for wheelchair-bound individuals) and guidance for self-practiced physio-, speech and occupational exercises will be prepared based on a standardized operational protocol drafted by the study team on the basis of published consensus recommendations, scientific evidence and principles of good clinical practice and adapted to the individual healthcare preferences and therapeutic needs of the recruited individuals. Six, 12 and 18 months after the baseline visit, in-person visits will be scheduled, including a comprehensive clinical, psychological and neuro-rehabilitation re-assessment of the individual therapeutic needs. Therapeutic adaptations will be made following the standardized operational protocol and adapted to the individual healthcare preferences. At month 12 the online semi-structured interview will be repeated to assess for eventual changes in the individual healthcare preferences due to the disease progression. At month 1, 7 and 13, follow-up phone calls will be scheduled to verify the compliance with the individualized treatment plan and identify barriers to its application. At month 1, 7, 13 and 18, the study participants will be invited to complete online satisfaction surveys with the overall individualized treatment plan. Twenty-three patients will be block-wise randomized to receive additional monthly and on-demand neurological, psychological, physio-, occupational and speech therapy (based on individual needs) telemedicine visits through the CHES teleconsultation facility of the Tirol Kliniken. Upon completion of the telemedicine visit (or on-demand mobile palliative interventions, for wheelchair-bound individuals, whenever needed and wished), brief satisfaction surveys will be sent to the study participants through the CHES platform. Informal caregivers of the individuals with MSA recruited in the present study will be invited to participate upon written informed consent in an 18 months observational study, with baseline and 12 months semi-structured online interviews and baseline, 6-, 12- and 18 months assessment of their QoL and caregivers' burden.

Official Title
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Medical Decision Making in Multiple System Atrophy: Developing Personalized Best Medical Care With Integrated Telemedicine and Mobile Palliative Care for Individuals With Multiple System Atrophy

Conditions
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Multiple System Atrophy

Intervention / Treatment
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* Other: Telemedicine visits
* Other: Multidisciplinary, personalized symptomatic treatment


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria For individuals with MSA: i. Age ≥30 years at the time of consent; ii. Diagnosed with clinically probable or clinically established MSA according to the current MDS MSA criteria (1); iii. Life-expectancy of at least 24 months as assessed by the investigator at the time of consent; iv. Understands and agrees to comply with the study procedures and provides written informed consent (Note: a legal representative may NOT provide consent on behalf of the subject); v. Signed and dated informed consent document; vi. Fluency in German; vii. Living in Tyrol, if not able to walk or stand without assistance/support at the time of consent. For informal caregivers: i. Informal caregiver (i.e. person not receiving payment for his/her caregiving) of an individual with MSA recruited in the present study; ii. Life-expectancy of at least 24 months as assessed by the investigator at the time of consent; iii. Age≥ 18 years at the time of consent; iv. Understands and agrees to provide information as outlined in the study protocol and to engage in semi-structured online interviews; v. Provides signed and dated written informed consent; vi. Full legal capacity; vii. Fluency in German. Exclusion Criteria For individuals with MSA i. Participation in an interventional clinical study at screening and throughout the study that would interfere with the MeDeMSA Care personalized treatment plan or would not permit telemedicine and mobile palliative care strategies; ii. Charlson comorbidity index >4 at the time of consent; iii. Other major underlying medical conditions that may confound interpretation of study results as assessed by the investigator.

Ages Eligible for Study
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Minimum Age: 30 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Group 1<br>Personalized best medical care. | Other: Multidisciplinary, personalized symptomatic treatment<br>* Multidisciplinary, personalized symptomatic treatment plus mobile palliative care interventions (if wished and needed)<br>|
| Experimental: Group 2<br>Personalized best medical care PLUS telemedicine | Other: Telemedicine visits<br>* Monthly telemedicine neurological, psychological and neurorehabilitation (physio-, occupational and speech therapy) consultations<br>Other: Multidisciplinary, personalized symptomatic treatment<br>* Multidisciplinary, personalized symptomatic treatment plus mobile palliative care interventions (if wished and needed)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in the EQ-5D-5L score | Assessment of improvement of the patient´s quality of life | Baseline to 18-months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in the MSA-QoL score and subscores | Assessment of improvement of the quality of life, specifically designed for people with MSA | Baseline to 6-, 12- and 18-months | 
| Change in motor and non-motor scales | It includes total and subscores, as video-based, rater-blinded assessment of the UMSARS motor score and Hoehn & Yahr changes over the study period. | Baseline to 6-, 12- and 18-months | 
| Time to clinical milestones | The clinical milestones are falls at least once a day, feeding by nasogastric tube or gastrostomy, unintelligible speech, indwelling catheter, wheelchair dependency. | over the 18-months study period | 
| Changes in the individual healthcare preferences assessed by means of the Autonomy Preference Index (API) | Assessment of individual preferences about the individual healthcare | Baseline to 12- months | 
| In-person and telemedicine medical, psychological and neurorehabilitation interventional needs of individuals with MSA | Registration of the need of support required by MSA patients | over the 18-months study period | 
| Change in the Short Assessment of Patient Satisfaction (SAPS) referred to the overall individualized treatment plan | Assessment of patients´ level of satisfaction with the individuaized treatment plan | Month 1 to 7, 13 and 18 | 
| Individual satisfaction with the single telemedicine and mobile palliative interventions | The individual satisfaction will be assessed by means of online numeric rating scales and open-ended questions | over the 18-months study period | 
| Healthcare professionals satisfaction with the single telemedicine and mobile palliative interventions | The individual healthcare professionals satisfaction will be assessed by means of online numeric rating scales and open-ended questions | over the 18-months study period | 
| Number of medical complications | Record of number of medical complications occurred (e.g. falls with or w/o injuries, urinary tract infections, choking, aspiration pneumonia, hospitalizations, death, others) | over the 18-months study period | 
| Single-intervention and cumulative healthcare costs | Record of healthcare costs | over the 18-months study period | 
| Changes in the EQ-5D-5L score of informal caregivers of individuals with MSA recruited in the present study | Assessment of improvement of caregivers´quality of life | Baseline to 6-, 12- and 18-months | 
| Change in the Carers quality-of-life questionnaire for parkinsonism (PQoL Carers) score and other caregiver-burden indicators in informal caregivers of individuals with MSA recruited in the present study | Assessment of improvement of caregivers´quality of life specifically designed for the caregivers of individuals diagnosed with Parkinsonisms | Baseline to 6-, 12- and 18-months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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MSA, Movement disorders, Autonomic dysfunctions, Telemedicine, Palliative care, Caregivers burden