用AI与数字助手优化医院到家的过渡期照护，降低再入院率。
New care pathways for supporting transitional care from hospitals to home using AI and personalized digital assistance
- 融合物联网、AI与数字辅助技术重构传统照护路径。
- 识别照护断点并设计技术映射方案，提升患者安全与生活质量。
- 提出临床试验框架，验证技术对医疗系统的积极影响。
过渡期照护对欧洲未来医疗体系的可持续性至关重要，可通过将患者照护从医院转移至家庭来应对老龄化带来的医疗需求增长。为确保有效实施，必须整合创新的信息与通信技术，以保障共病患者从医院或照护中心平稳、协调地过渡至家中，从而降低再入院风险。本文综述了物联网、人工智能与数字辅助技术与传统照护路径的融合策略，识别当前过渡期照护的短板，并定义技术映射方案以优化照护流程，目标是改善患者结局、安全性和生活质量，避免再入院。最后，我们提出了试验设计与评估方法，以提供技术整合对患者照护产生积极影响的临床证据，并探讨其对医疗系统可能产生的影响。
原文摘要 · Abstract (English)
Transitional care may play a vital role for the sustainability of Europe future healthcare system, offering solutions for relocating patient care from hospital to home therefore addressing the growing demand for medical care as the population is ageing. However, to be effective, it is essential to integrate innovative Information and Communications Technology technologies to ensure that patients with comorbidities experience a smooth and coordinated transition from hospitals or care centers to home, thereby reducing the risk of rehospitalization. In this paper, we present an overview of the integration of Internet of Things, artificial intelligence, and digital assistance technologies with traditional care pathways to address the challenges and needs of healthcare systems in Europe. We identify the current gaps in transitional care and define the technology mapping to enhance the care pathways, aiming to improve patient outcomes, safety, and quality of life avoiding hospital readmissions. Finally, we define the trial setup and evaluation methodology needed to provide clinical evidence that supports the positive impact of technology integration on patient care and discuss the potential effects on the healthcare system.
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