The effectiveness of a mHealth-based integrated hospital-community-home program for people with type 2 diabetes in transitional care: a protocol for a multicenter pragmatic randomized controlled trial

作者：Wenhui Zhang, Pei Yang, Hongyan Wang, Xinxin Pan, Yanmei Wang · 发表于：BMC Family Practice · 年份：2022 · DOI：10.1186/s12875-022-01814-8 · 被引用次数：16 · 研究领域：Diabetes Management and Education、Chronic Disease Management Strategies、Primary Care and Health Outcomes

BACKGROUND: Diabetes is a progressive condition requiring long-term medical care and self-management. The ineffective transition from hospital to community or home health care may result in poor glycemic control and increase the risk of serious diabetes-related complications. In China, the most common transitional care model is home visits or telephone interventions led by a single healthcare setting, with a lack of cooperation between specialists and primary care, which leads to inadequate service and discontinuous care. Thus, an integrated hospital-community-home (i-HCH) transitional care program was developed to promote hospital and community cooperation and provide comprehensive and continuous medical care for type 2 diabetes mellitus (T2DM) via mobile health (mHealth) technology. METHODS: This protocol is for a multicenter randomized controlled trial in T2DM patients. Hospitalized patients diagnosed with T2DM who meet the eligibility criteria will be recruited. The patients will be randomly allocated to either the intervention or the control group and receive the i-HCH transitional care or usual transitional care intervention. The change in glycated hemoglobin is the primary outcome. Secondary outcome measures are blood pressure, lipids (total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein), body mass index, self-management skills, quality of life, diabetes knowledge, transitional care satisfaction and the rate of readmission. The follow-up...