【中图分类号】R36【文献标识码】A DOI：10.12114/j.issn.1007-9572.2024.0479

【Abstract】BackgroundWith adva nces in medical technology，more than 9O percent of children with chronic diseases need tobe transitioned from pediatric toadultcare，andthegreater number ofchronic diseasesachildhas，the higherrisk ofmorbidityand mortality.However，untilnow，research in China focused mainlyonmultiplechronic diseases in adults，andtherearenosystematicandcomprehensiveinterventionsforthetransitionofchildrenwithmultiplechronicdiseases. ObjectiveToformhealthcare transition intervention modelsfor multiplechronicdiseases inchildrenbasedontheE-Coach managementmodel.MethodsInApril2O24，asystematicsearchwasconductedfordomesticandinternationaliteratureonthe medical transitionofchildrenwith multiplechronicdiseases.Tworesearchers independentlyscreenedtheliterature，evaluated themethodologicalqualityoftheincludedliterature，extractedandsummarizedtheevidence，andinitiallformedanintervention modelforthemedical transitionofchildrenwithmultiplechronicdiseasesbasedontheE-Coach management modelafter discussionintheresearch group.From Mayto June2O24，tworoundsofcorrespondence wereconducted with expertsusing the expertorrspondencemethod，andthemedicaltrasitioniterventiomodelwasfinalizedbycalculatingthecoeficientofexpet positivity，thecoffientofexpertuthority，thecoeffietfexpertcoordination，andthecoeffcientofvariationforachlevel of entries.ResultsAtotalof1734 documents were searched，and11documents werefinallincluded，summarizing 36 pieces of evidence involvingfouraspects：interventiongoals，interventionforms，intervention argets，and interventionmeasures. TheE-Coach management model-based multiplechronicdisease medicaltransition interventionmodel forchildren，which was initially constructed after discussionbytheresearch group，contains4 primary indicators，13 secondary indicators，and 21 tertiary indicators.The recovery rates of the two rounds of expert questionnaires were 100.0% ，theexpert authoritycoefficients were 0.813 and O.830，theKendall's W coefficients of the importance of the indicators were 0.270（ χ²=149.866 ， P lt;0.001） and 0.321（ χ² =154.058， Plt;0.001 ），and the Kendall's W coefficients of the feasibility of the indicators were 0.266（ χ² =147.396， Plt;0.001 ），0.362（ χ² =173.605， Plt;0.001 ），respectively. The finalized medical transition intervention model for children with multiplechronicdiseasesbasedonthe E-Coach management model included four primary indicators （interventiontarget， interventionteam，intervention form，and intervention measures），10secondaryindicators，and19 tertiaryindicators.

ConclusionThe medical transition intervention modelforchildren with multiplechronicdiseases basedontheE-Coach management model hasstrong reliabilityandoperability，andcan provide guidanceforclinical healthcare profesionals tocarry outmedical transitioninterventions for children with multiple chronic diseases.

【Key words】 Health management；E-Coach；Multimorbidity；Medical transition；Delphi；Children

随着医疗技术的进步，超过 90% 的慢性非传染性疾病（以下简称“慢病”）患儿的生存时间得以延长，能存活至成年[1]。由于年龄的增长及医疗状况的改变，慢病患儿需从儿科医疗系统转移至成人科医疗系统[2]在医疗过渡的过程中，若患儿家庭及其医疗人员未做好医疗过渡相关准备，且患儿所患慢病数量越多，则会导致急诊就诊率增加，治疗依从性降低，发病和死亡风险增加[3-4]。多种慢病之间的相互作用对个体健康产生重要威胁，但迄今为止，研究主要集中在成年多重慢病方面[5]。目前，多重慢病儿童医疗过渡在我国仍处于初步探索阶段，仅有医疗过渡相关文献综述及调查研究[6-7]，较少有系统完善的医疗过渡干预措施。因此，构建一个儿童多重慢病医疗过渡干预模型对疾病进行管理是十分必要的。线上线下一体化健康教练慢病管理模式（简称E-Coach管理模式）是一种新兴慢病管理模式，与网络技术相融合，建立医院－家庭慢病管理系统，助力医疗过渡期患儿提高治疗依从性及疾病管理能力[]，进而做好医疗过渡相关准备。目前，E-Coach管理模式在国外得到广泛应用与发展[9-10]，但在我国仍处于探索阶段。因此，本研究拟通过文献研究、专家函询等方法，建立基于E-Coach管理模式的儿童多重慢病医疗过渡干预模型的具体框架，为临床制订多重慢病儿童医疗过渡具体方案和开展相关实践提供参考。

1对象与方法

1.1初步形成基于E-Coach管理模式的儿童多重慢病医疗过渡干预模型