多病和糖尿病医生网络:NOMAD干预的发展-糖尿病和多病患者的多学科团队。

IF 3
Journal of multimorbidity and comorbidity Pub Date : 2025-08-26 eCollection Date: 2025-01-01 DOI:10.1177/26335565251366466
Stine Jorstad Bugge, Jørgen Hangaard, Per Damkier, Per Bruno Jensen, Sofie Lock Johansson, Subagini Nagarajah, Vasiliki Panou, Marianne Kjær Poulsen, Martin Torp Rahbek, Mette Bøg Horup, Mette Juel Rothmann, Karoline Schousboe, Ida Ransby Schneider, Daniel Pilsgaard Henriksen, Ann-Dorthe Olsen Zwisler
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引用次数: 0

摘要

目的:本文报道NOMAD干预的发展,这是一种多学科团队会议的模式,旨在改善多病和糖尿病患者的护理协调和治疗。管理多种慢性疾病增加了护理的复杂性,多学科方法可以增强护理一致性,优化治疗并改善生活质量。方法:在医学研究理事会制定复杂干预措施框架的指导下,我们成立了一个工作组,制定了一个方案理论,并通过对患者和医生的定性访谈进行了初步测试。干预的目标是糖尿病和并发慢性疾病影响心脏、肺或肾脏的患者。结果:NOMAD干预是一个结构化的模型,包括内分泌学、心脏病学、呼吸医学、肾脏病学和药理学专家的定期、面对面的多学科团队会议。一个关键组成部分是整合患者报告的结果,以加强以患者为中心的护理,突出生活质量方面。结论:这一发展过程为NOMAD在随机试验中的可行性测试和未来评价提供了基础。我们的经验也可以为研究人员和医疗保健提供者提供信息,为复杂的患者群体开发类似的多学科干预措施。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Network of doctors for multimorbidity and diabetes: Development of the NOMAD intervention - a multidisciplinary team for patients with diabetes and multimorbidity.

Network of doctors for multimorbidity and diabetes: Development of the NOMAD intervention - a multidisciplinary team for patients with diabetes and multimorbidity.

Network of doctors for multimorbidity and diabetes: Development of the NOMAD intervention - a multidisciplinary team for patients with diabetes and multimorbidity.

Network of doctors for multimorbidity and diabetes: Development of the NOMAD intervention - a multidisciplinary team for patients with diabetes and multimorbidity.

Purpose: This article reports the development of the NOMAD intervention, a model of multidisciplinary team conferences designed to improve care coordination and treatment for patients with multimorbidity and diabetes. Managing multiple chronic conditions increases care complexity, and multidisciplinary approaches may enhance care coherence, optimise treatment, and improve quality of life.

Method: Guided by the Medical Research Council framework for developing complex interventions, we established a working group, formulated a programme theory, and conducted a preliminary test with qualitative interviews of patients and physicians. The intervention targets patients with diabetes and concurrent chronic conditions affecting the heart, lungs, or kidneys.

Results: The NOMAD intervention was developed as a structured model of regular, in-person multidisciplinary team conferences involving specialists in endocrinology, cardiology, respiratory medicine, nephrology, and pharmacology. A key component was the integration of patient-reported outcomes to enhance patient-centred care, highlighting the aspect of quality of life.

Conclusion: This development process provides a foundation for feasibility testing and future evaluation of NOMAD's impact in a randomised trial. Our experiences may also inform researchers and healthcare providers developing similar multidisciplinary interventions for complex patient populations.

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