关键词: 健康管理, E-Coach, 多重慢病, 医疗过渡期, 德尔菲法, 儿童

Abstract: Background　With advances in medical technology，more than 90 per cent of children with chronic diseases need to be transitioned from pediatric to adult care，and the greater the number of chronic diseases a child has，the higher the risk of morbidity and mortality. However，to date，research in China has focused mainly on multiple chronic diseases in adults，and there are currently no systematic and comprehensive interventions for the transition of children with multiple chronic diseases. Objective　Modeling healthcare transition interventions for multiple chronic diseases in children based on the E-Coach management model. Methods　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. In May-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. Results　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. Conclusion　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.

Key words: Health management, E-Coach, Multimorbidity, Medical transition, Delphi, Children