With adva nces in medical technology, more than 90 percent of children with chronic diseases need to be transitioned from pediatric to adult care, and the greater number of chronic diseases a child has, the higher risk of morbidity and mortality. However, until now, research in China focused mainly on multiple chronic diseases in adults, and there are no systematic and comprehensive interventions for the transition of children with multiple chronic diseases.

To form healthcare transition intervention models for multiple chronic diseases in children based on the E-Coach management model.

In April 2024, a systematic search was conducted for domestic and international literature on the medical transition of children with multiple chronic diseases. Two researchers independently screened the literature, evaluated the methodological quality of the included literature, extracted and summarized the evidence, and initially formed an intervention model for the medical transition of children with multiple chronic diseases based on the E-Coach management model after discussion in the research group. From May to June 2024, two rounds of correspondence were conducted with experts using the expert correspondence method, and the medical transition intervention model was finalized by calculating the coefficient of expert positivity, the coefficient of expert authority, the coefficient of expert coordination, and the coefficient of variation for each level of entries.

A total of 1 734 documents were searched, and 11 documents were finally included, summarizing 36 pieces of evidence involving four aspects: intervention goals, intervention forms, intervention targets, and intervention measures. The E-Coach management model-based multiple chronic disease medical transition intervention model for children, which was initially constructed after discussion by the research group, contains 4 primary indicators, 13 secondary indicators, and 21 tertiary indicators. The recovery rates of the two rounds of expert questionnaires were 100.0%, the expert authority coefficients were 0.813 and 0.830, the Kendall's W coefficients of the importance of the indicators were 0.270 (χ²=149.866, P<0.001) and 0.321 (χ²=154.058, P<0.001), and the Kendall's W coefficients of the feasibility of the indicators were 0.266 (χ²=147.396, P<0.001), 0.362 (χ²=173.605, P<0.001), respectively. The finalized medical transition intervention model for children with multiple chronic diseases based on the E-Coach management model included four primary indicators (intervention target, intervention team, intervention form, and intervention measures), 10 secondary indicators, and 19 tertiary indicators.

The medical transition intervention model for children with multiple chronic diseases based on the E-Coach management model has strong reliability and operability, and can provide guidance for clinical healthcare professionals to carry out medical transition interventions for children with multiple chronic diseases.

随着医疗技术的进步，超过90%慢病患儿需从儿科医疗过渡至成人医疗，且患儿所患慢病数量越多，其发病和死亡风险越高。迄今为止，我国研究主要集中在成人多重慢病方面，目前尚无系统完善的多重慢病儿童医疗过渡干预措施。

构建基于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）的儿童多重慢病医疗过渡干预模型。

于2024年4月，系统检索国内外儿童多重慢病医疗过渡期相关文献，由2位研究者进行独立筛选，对纳入文献进行方法学质量评估后，提取并汇总证据，经课题组讨论，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。于2024年5—6月，经过两轮专家函询后，通过计算专家的积极系数、权威系数、协调系数，以及各级指标的变异系数确定最终的医疗过渡干预模型。

共检索到1 734篇文献，最终纳入11篇文献，汇总得到涉及干预目标、干预形式、干预对象、干预措施4个方面的36条证据。经课题组讨论初步构建的基于E-Coach管理模式的儿童多重慢病医疗过渡干预模型包含4项一级指标、13项二级指标和21项三级指标。2轮专家函询问卷回收率均为100.0%，专家权威系数分别为0.813、0.830，指标重要性的Kendall's W系数分别为0.270（χ²=149.866，P<0.001）、0.321（χ²=154.058，P<0.001），指标可行性的Kendall's W系数分别为0.266（χ²=147.396，P<0.001）、0.362（χ²=173.605，P<0.001）。最终形成的基于E-Coach管理模式的儿童多重慢病医疗过渡干预模型包括一级指标4项、二级指标10项、三级指标19项。

基于E-Coach管理模式的儿童多重慢病医疗过渡干预模型具有较高的可靠性和可操作性，能为临床医护人员开展儿童多重慢病医疗过渡干预工作提供指导。