The Impact of Nurse Practitioner-Led Multidisciplinary Team Intervention on the Implementation of Guideline-Directed Medical Therapy and Clinical Outcomes in Adults With Multimorbidity

NCT07138183 | Active Not Recruiting

• 1 other identifier: 202506113RINC
• Study Type: interventional
• Target: 178
• Locations: 1 country
• Sites: 1

Brief Summary

The goal of this clinical trial is to evaluate whether a nurse practitioner-led multidisciplinary team (NP-led MDT) intervention can improve the use of guideline-directed medical therapy (GDMT) and short-term clinical outcomes in hospitalized adults with multimorbidity in a multidisciplinary medicine ward. The main questions it aims to answer are: Does NP-led MDT intervention increase the proportion of patients achieving GDMT at hospital discharge? Does NP-led MDT intervention reduce 30-, 60-, and 90-day readmission, emergency department visits, and mortality? Researchers will compare the NP-led MDT intervention group with the usual care group to see if the intervention improves GDMT implementation and clinical outcomes. Participants will: Be randomly assigned to NP-led MDT care or usual care. Have their medications reviewed according to the latest guidelines (intervention group only). Be followed for 90 days after discharge to collect outcomes through medical record review and telephone follow-up.

Conditions

Multimorbidity

Outcome Measures

Primary Outcomes (1)

• GDMT Implementation Rate at Hospital Discharge

  The proportion of guideline-directed medical therapy (GDMT) drugs prescribed at hospital discharge, calculated as the number of GDMT drug classes prescribed divided by the number of drug classes indicated.

  On the day of hospital discharge

Study Arms (2)

NP-led MDT Intervention Group

EXPERIMENTAL

Participants receive care from a nurse practitioner-led multidisciplinary team providing individualized, guideline-based medication recommendations.

Behavioral: NP-led MDT

Usual Care Group

ACTIVE COMPARATOR

Participants receive usual inpatient care from the primary care team without additional NP-led MDT intervention.

Behavioral: Usual Care

Interventions

NP-led MDT BEHAVIORAL

a nurse practitioner-led multidisciplinary team (MDT).

NP-led MDT Intervention Group

Usual Care BEHAVIORAL

Participants will receive usual inpatient care provided by the primary care team.

Usual Care Group

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Age: 18 years or older
• Admitted to the multidisciplinary ward through the emergency department for inpatient care
• Diagnosed with at least one of the following six chronic conditions and concurrently having one or more additional chronic diseases:
• Congestive Heart Failure (CHF)
• Diabetes Mellitus (DM)
• Hypertension (HTN)
• Dyslipidemia (DLP)
• Atrial Fibrillation (AF)
• Chronic Kidney Disease (CKD)

You may not qualify if:

• End-of-life (EOL) patients: Refers to patients receiving palliative care or those assessed by the medical team as unlikely to survive to discharge during the current hospitalization.
• Patients expected to be transferred to other departments: For example, patients anticipated to be transferred to oncology, intensive care unit (ICU), surgery, or other departments where full MDT intervention cannot be implemented.
• Unwilling to participate.
• Patients under the care of the study team physician on the day of hospitalization.
• Patients known to be economically or educationally disadvantaged

Sponsors & Collaborators

• National Taiwan University Hospital: lead

Study Sites (1)

National Taiwan University Hospital

Taipei, 100, Taiwan

Location

Related Publications (8)

• Spahillari A, Cohen LP, Lin C, Liu Y, Tringale A, Sheppard KE, Ko C, Khairnar R, Williamson KM, Wasfy JH, Scott NS, Paquette C, Greene SJ, Fonarow GC, Januzzi JL Jr. Efficacy, Safety and Mechanistic Impact of a Heart Failure Guideline-Directed Medical Therapy Clinic. JACC Heart Fail. 2025 Apr;13(4):554-568. doi: 10.1016/j.jchf.2024.08.017. Epub 2024 Oct 9.

  PMID: 39387769 RESULT

• AlHabeeb W, Alayoubi F, Hayajneh A, Ullah A, Elshaer F. A strategy to improve adherence to guideline-directed medical therapy (GDMT) and the role of the multidisciplinary team in a heart-failure programme. Cardiovasc J Afr. 2024 Jan-Apr 23;35(1):12-15. doi: 10.5830/CVJA-2022-067. Epub 2023 May 5.

  PMID: 37171293 RESULT

• Rao VU, Bhasin A, Vargas J Jr, Arun Kumar V. A multidisciplinary approach to heart failure care in the hospital: improving the patient journey. Hosp Pract (1995). 2022 Aug;50(3):170-182. doi: 10.1080/21548331.2022.2082776. Epub 2022 Jul 4.

  PMID: 35658810 RESULT

• Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024 Apr;105(4S):S117-S314. doi: 10.1016/j.kint.2023.10.018. No abstract available.

  PMID: 38490803 RESULT

• Huang PH, Lu YW, Tsai YL, Wu YW, Li HY, Chang HY, Wu CH, Yang CY, Tarng DC, Huang CC, Ho LT, Lin CF, Chien SC, Wu YJ, Yeh HI, Pan WH, Li YH; expert committee for the Taiwan Lipid Guidelines for Primary Prevention. 2022 Taiwan lipid guidelines for primary prevention. J Formos Med Assoc. 2022 Dec;121(12):2393-2407. doi: 10.1016/j.jfma.2022.05.010. Epub 2022 Jun 14.

  PMID: 35715290 RESULT

• Wang TD, Chiang CE, Chao TH, Cheng HM, Wu YW, Wu YJ, Lin YH, Chen MY, Ueng KC, Chang WT, Lee YH, Wang YC, Chu PH, Chao TF, Kao HL, Hou CJ, Lin TH. 2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension. Acta Cardiol Sin. 2022 May;38(3):225-325. doi: 10.6515/ACS.202205_38(3).20220321A.

  PMID: 35673334 RESULT

• Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR; Peer Review Committee Members. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jan 2;149(1):e1-e156. doi: 10.1161/CIR.0000000000001193. Epub 2023 Nov 30.

  PMID: 38033089 RESULT

• Li YH, Wang CC, Hung CL, Wu YW, Hsu CH, Tsou YL, Wang CH, Wu CK, Lin PL, Chang HY, Sung SH, Chen ZW, Juang JJ, Wang TD, Chen WJ. 2024 Guidelines of the Taiwan Society of Cardiology for the Diagnosis and Treatment of Heart Failure with Preserved Ejection Fraction. Acta Cardiol Sin. 2024 Mar;40(2):148-171. doi: 10.6515/ACS.202403_40(2).20240206A.

  PMID: 38532817 RESULT

Study Officials

• Hsiao-Chen Chou Nurse Practitioner

  National Taiwan University Hospital

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: DOUBLE
• Who Masked: PARTICIPANT, OUTCOMES ASSESSOR
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Principal Investigator

Study Record Dates

• First Submitted: August 5, 2025
• First Posted: August 22, 2025
• Study Start: September 2, 2025
• Primary Completion: November 24, 2025
• Study Completion: April 1, 2026
• Last Updated: March 19, 2026

Record last verified: 2026-03

Data Sharing

• IPD Sharing: Will not share

Locations

TW (1)