{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T18:33:35Z","timestamp":1792175615437,"version":"4.4.0"},"reference-count":60,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T00:00:00Z","timestamp":1765756800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Chronic diseases represent one of the most complex, costly, and significant challenges for healthcare systems. The increase in chronic conditions and multimorbidity, together with the growing demand for continuity of care makes the vulnerability of the hospital-to-community transition increasingly evident. This phase is often characterized by delays, fragmented services, and insufficient support for patients and caregivers, leading to higher rates of early readmission and substantial clinical, social, and economic impacts. This paper was developed through a narrative synthesis of international and national literature on continuity of care, integrated models, and nurse-led experiences. Based on this synthesis, an integrated six-phase nursing model is proposed, combining predictive assessment tools and telemedicine to enhance early risk identification, proactive discharge planning, and post-discharge follow-up. Evidence indicates that nurse-led interventions supported by digital solutions can reduce inappropriate hospital days, decrease hospital readmissions, and improve patient and caregiver satisfaction. The integration of predictive tools and telemedicine solutions, coordinated by nurse case managers, represents a promising strategy to strengthen continuity of care and the sustainability of the healthcare system, and the proposed conceptual model highlights practical implications while outlining future research directions for empirical validation and large-scale implementation.<\/jats:p>","DOI":"10.3390\/medicina61122213","type":"journal-article","created":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T13:32:37Z","timestamp":1765805557000},"page":"2213","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Bridging the Gap in Chronic Disease Management: A Nursing Perspective on the Use of Predictive Tools and Telemedicine in the Hospital\u2013Community Transition"],"prefix":"10.3390","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-7891-0463","authenticated-orcid":false,"given":"Gianluca","family":"Azzellino","sequence":"first","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Complex Operational Unit, Adriatic District Area, AUSL 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mauro","family":"Passamonti","sequence":"additional","affiliation":[{"name":"Complex Operational Unit, Adriatic District Area, AUSL 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0452-3282","authenticated-orcid":false,"given":"Ernesto","family":"Aitella","sequence":"additional","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-4919-8756","authenticated-orcid":false,"given":"Luca","family":"Mengoli","sequence":"additional","affiliation":[{"name":"Long-Term Care Unit, \u201cMaria SS. dello Splendore\u201d Hospital, AUSL 04 Teramo, 64021 Giulianova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-9049-8467","authenticated-orcid":false,"given":"Patrizia","family":"Vagnarelli","sequence":"additional","affiliation":[{"name":"Complex Operational Unit, Adriatic District Area, AUSL 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1841-2807","authenticated-orcid":false,"given":"Lia","family":"Ginaldi","sequence":"additional","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, 64100 Teramo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4253-1312","authenticated-orcid":false,"given":"Massimo","family":"De Martinis","sequence":"additional","affiliation":[{"name":"Department of Life, Health and Environmental Sciences, University of L\u2019Aquila, 67100 L\u2019Aquila, Italy"},{"name":"Long-Term Care Unit, \u201cMaria SS. dello Splendore\u201d Hospital, AUSL 04 Teramo, 64021 Giulianova, Italy"},{"name":"UniCamillus\u2014Saint Camillus International University of Health Sciences, 00131 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,15]]},"reference":[{"key":"ref_1","unstructured":"(2025, October 16). Health at a Glance: Europe 2024. Available online: https:\/\/www.oecd.org\/en\/publications\/health-at-a-glance-europe-2024_b3704e14-en.html."},{"key":"ref_2","unstructured":"Ministero della Salute (2020). Piano Nazionale della Cronicit\u00e0."},{"key":"ref_3","unstructured":"Ministero della Salute (2022). Decreto 23 maggio 2022, n. 77. Regolamento Recante la Definizione di MODELLI e Standard per lo Sviluppo Dell\u2019assistenza Territoriale nel Servizio Sanitario Nazionale, Gazzetta Ufficiale della Repubblica Italiana."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1136\/bmjqs.2010.048470","article-title":"Hospital discharge documentation and risk of rehospitalisation","volume":"20","author":"Hansen","year":"2011","journal-title":"BMJ Qual. Saf."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1111\/j.1532-5415.2004.52202.x","article-title":"Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial","volume":"52","author":"Naylor","year":"2004","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1822","DOI":"10.1001\/archinte.166.17.1822","article-title":"The care transitions intervention: Results of a randomized controlled trial","volume":"166","author":"Coleman","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"36593","DOI":"10.56305\/001c.36593","article-title":"Nonmedical Discharge Barriers in Prolonged Stays on a General Medicine Ward: A Retrospective Review","volume":"1","author":"Gao","year":"2022","journal-title":"Brown J. Hosp. Med."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Vinci, A., Furia, G., Cammalleri, V., Colamesta, V., Chierchini, P., Corrado, O., Mammarella, A., Ingravalle, F., Bardhi, D., and Malerba, R.M. (2024). Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0294785"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Binda, F., Marelli, F., Cesana, V., Rossi, V., Boasi, N., and Lusignani, M. (2025). Prevalence of Delayed Discharge Among Patients Admitted to the Internal Medicine Wards: A Cross-Sectional Study. Nurs. Rep., 15.","DOI":"10.3390\/nursrep15030098"},{"key":"ref_10","first-page":"e85879","article-title":"Reducing Delays, Improving Flow: The Importance of a Dedicated Discharge Coordinator in Hospital Discharge Planning","volume":"17","author":"Bechir","year":"2025","journal-title":"Cureus"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Azzellino, G., Vagnarelli, P., Passamonti, M., Mengoli, L., Ginaldi, L., and De Martinis, M. (2025). Integrated Hospital\u2013Territory Organizational Models and the Role of Family and Community Nurses in the Management of Chronic Conditions: A Scoping Review. Medicina, 61.","DOI":"10.3390\/medicina61071175"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"23743735221086756","DOI":"10.1177\/23743735221086756","article-title":"Post-Discharge Transitional Care Program and Patient Compliance with Follow-Up Activities","volume":"9","author":"Bhandari","year":"2022","journal-title":"J. Patient Exp."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1111\/hex.12916","article-title":"Patient and caregiver experience with delayed discharge from a hospital setting: A scoping review","volume":"22","author":"Everall","year":"2019","journal-title":"Health Expect."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Stergiopoulos, G.M., Elayadi, A.N., Chen, E.S., and Galiatsatos, P. (2024). The effect of telemedicine employing telemonitoring instruments on readmissions of patients with heart failure and\/or COPD: A systematic review. Front. Digit. Health, 6.","DOI":"10.3389\/fdgth.2024.1441334"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e53455","DOI":"10.2196\/53455","article-title":"Efficacy of Remote Health Monitoring in Reducing Hospital Readmissions Among High-Risk Postdischarge Patients: Prospective Cohort Study","volume":"8","author":"Po","year":"2024","journal-title":"JMIR Form. Res."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"170","DOI":"10.1016\/j.ejim.2025.03.035","article-title":"Protected discharge and combined interventions: A viable path to reduce hospital readmissions","volume":"138","author":"Azzellino","year":"2025","journal-title":"Eur. J. Intern. Med."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Azzellino, G., Aitella, E., Ginaldi, L., Vagnarelli, P., and De Martinis, M. (2025). Use of Digital and Telemedicine Tools for Postoperative Pain Management at Home: A Scoping Review of Health Professionals\u2019 Roles and Clinical Outcomes. J. Clin. Med., 14.","DOI":"10.3390\/jcm14114009"},{"key":"ref_18","unstructured":"World Health Organization (2016). Framework on Integrated, People-Centred Health Services: Report by the Secretariat (A69\/39), World Health Organization."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Scrimaglia, S., Ricci, M., Masini, A., Montalti, M., Conti, A., Camedda, C., Panella, M., Dallolio, L., Longobucco, Y., and Scrimaglia, S. (2024). The Role of Family or Community Nurse in Dealing with Frail and Chronic Patients in Italy: A Scoping Review. Geriatrics, 9.","DOI":"10.3390\/geriatrics9030081"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e70091","DOI":"10.1002\/nop2.70091","article-title":"Renewing the Role of the Nursing Coordinator: Towards Modern and Effective Leadership in Healthcare","volume":"11","author":"Azzellino","year":"2024","journal-title":"Nurs. Open"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"6981","DOI":"10.1111\/jan.16552","article-title":"Renew the Nursing Profession to Attract New Forces and Be Increasingly Inclusive and Attentive to Diversity","volume":"81","author":"Azzellino","year":"2024","journal-title":"J. Adv. Nurs."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1016\/j.cmpb.2018.06.006","article-title":"Predictive models for hospital readmission risk: A systematic review of methods","volume":"164","author":"Artetxe","year":"2018","journal-title":"Comput. Methods Programs Biomed."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e002495","DOI":"10.1136\/bmjoq-2023-002495","article-title":"Telehealth-based transitional care management programme to improve access to care","volume":"12","author":"Elsener","year":"2023","journal-title":"BMJ OPEN Qual."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1177\/1077558716647652","article-title":"Discharge Planning and Hospital Readmissions","volume":"74","author":"Henke","year":"2017","journal-title":"Med. Care Res. Rev."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1597","DOI":"10.1111\/jgs.14828","article-title":"Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review","volume":"65","author":"Maimon","year":"2017","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1097\/NCM.0000000000000425","article-title":"Roles, Training, and Qualifications of a Case Manager in the Canadian Health Care Industry: A Narrative Review","volume":"26","author":"Mwandala","year":"2021","journal-title":"Prof. Case Manag."},{"key":"ref_27","first-page":"19","article-title":"The process of developing the Professional Identity of the Nurse Case Care Manager: A Grounded Theory study","volume":"91","author":"Bertuol","year":"2020","journal-title":"Acta Biomed."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"375","DOI":"10.3390\/diabetology5040029","article-title":"Lifestyle Medicine Case Manager Nurses for Type Two Diabetes Patients: An Overview of a Job Description Framework-A Narrative Review","volume":"5","author":"Cangelosi","year":"2024","journal-title":"Diabetology"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1111\/inr.12987","article-title":"Nurse burnout: It is an urgent issue affecting the profession","volume":"71","author":"Ginaldi","year":"2024","journal-title":"Int. Nurs. Rev."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Villarreal-Granda, P., Recio-Platero, A., Mart\u00edn-Bayo, Y., Durantez-Fern\u00e1ndez, C., C\u00e1rdaba-Garc\u00eda, R.M., P\u00e9rez-P\u00e9rez, L., Madrigal, M., Mu\u00f1oz-Del Caz, A., Olea, E., and Bahillo Ruiz, E. (2024). Models Used by Nurse Case Managers in Different Autonomous Communities in Spain: A Scoping Review. Healthcare, 12.","DOI":"10.3390\/healthcare12070749"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1097\/NCM.0000000000000588","article-title":"Discharge Delay: How Can We Help Ourselves, Patients, and Families","volume":"28","author":"Armold","year":"2023","journal-title":"Prof. Case Manag."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1080\/08959420.2019.1578607","article-title":"Barriers to a Timely Discharge from Short-Term Care in VA Community Living Centers","volume":"32","author":"Tyler","year":"2020","journal-title":"J. Aging Soc. Policy"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e2344825","DOI":"10.1001\/jamanetworkopen.2023.44825","article-title":"Transitional Care Interventions from Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis","volume":"6","author":"Tyler","year":"2023","journal-title":"JAMA Netw. Open"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"5","DOI":"10.3928\/0098-9134-19920701-05","article-title":"Discharge planning predicting patients\u2019 needs","volume":"18","author":"Blaylock","year":"1992","journal-title":"J. Gerontol. Nurs."},{"key":"ref_35","first-page":"e2021039","article-title":"Hospital discharge: Testing the \u201cBlaylock Risk Assessment Screening Score\u201d in a surgical department","volume":"92","author":"Colognesi","year":"2021","journal-title":"Acta Biomed."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Louis Simonet, M., Kossovsky, M.P., Chopard, P., Sigaud, P., Perneger, T.V., and Gaspoz, J.-M. (2008). A predictive score to identify hospitalized patients\u2019 risk of discharge to a post-acute care facility. BMC Health Serv. Res., 8.","DOI":"10.1186\/1472-6963-8-154"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"e266","DOI":"10.37765\/ajmc.2024.89605","article-title":"Care transition management and patient outcomes in hospitalized Medicare beneficiaries","volume":"30","author":"Hardy","year":"2024","journal-title":"Am. J. Manag. Care"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"e044291","DOI":"10.1136\/bmjopen-2020-044291","article-title":"Initiatives for improving delayed discharge from a hospital setting: A scoping review","volume":"11","author":"Cadel","year":"2021","journal-title":"BMJ Open"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1007\/s10916-021-01793-w","article-title":"Understanding the Accuracy of Clinician Provided Estimated Discharge Dates","volume":"46","author":"Henry","year":"2021","journal-title":"J. Med. Syst."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"44","DOI":"10.36401\/JQSH-20-27","article-title":"Reducing the Length of Stay by Enhancing the Patient Discharge Process: Using Quality Improvement Tools to Optimize Hospital Efficiency","volume":"4","author":"Abuzied","year":"2021","journal-title":"Glob. J. Qual. Saf. Healthc."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"12","DOI":"10.3390\/nursrep14010002","article-title":"Evaluation of Delayed Effective Discharge for Non-Medical Reasons in Patients Admitted to Acute Care Hospitals in Spain: A Scoping Review","volume":"14","author":"Luis","year":"2023","journal-title":"Nurs. Rep."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1177\/1062860619846559","article-title":"Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients","volume":"35","author":"Meo","year":"2020","journal-title":"Am. J. Med. Qual."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"12","DOI":"10.5334\/ijic.3431","article-title":"Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment","volume":"18","author":"Aibar","year":"2018","journal-title":"Int. J. Integr. Care"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Lin, L., Cheng, M., Guo, Y., Cao, X., Tang, W., Xu, X., Cheng, W., and Xu, Z. (2024). Early discharge hospital at home as alternative to routine hospital care for older people: A systematic review and meta-analysis. BMC Med., 22.","DOI":"10.1186\/s12916-024-03463-3"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1097\/PTS.0000000000000596","article-title":"Effectiveness of Discharge Education With the Teach-Back Method on 30-Day Readmission: A Systematic Review","volume":"17","author":"Oh","year":"2021","journal-title":"J. Patient Saf."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1097\/RNJ.0000000000000452","article-title":"The Effect of Teach-Back on Readmission Rates in Rehabilitation Patients","volume":"49","author":"Bidlespacher","year":"2024","journal-title":"Rehabil. Nurs. J."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1097\/01.NAJ.0000336420.34946.3a","article-title":"Transitional Care: Moving patients from one care setting to another","volume":"108","author":"Naylor","year":"2008","journal-title":"Am. J. Nurs."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Sakashita, C., Endo, E., Ota, E., and Oku, H. (2025). Effectiveness of nurse-led transitional care interventions for adult patients discharged from acute care hospitals: A systematic review and meta-analysis. BMC Nurs., 24.","DOI":"10.1186\/s12912-025-03040-w"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"3930","DOI":"10.1111\/jan.15427","article-title":"A mixed-methods systematic review of nurse-led interventions for people with multimorbidity","volume":"78","author":"McParland","year":"2022","journal-title":"J. Adv. Nurs."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"16","DOI":"10.5334\/ijic.5518","article-title":"Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review","volume":"21","author":"Karam","year":"2021","journal-title":"Int. J. Integr. Care"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"4518","DOI":"10.1111\/jocn.17348","article-title":"Territorial reorganization, telemedicine and operative centres: Challenges and opportunities for the nursing profession","volume":"33","author":"Azzellino","year":"2024","journal-title":"J. Clin. Nurs."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"809","DOI":"10.3109\/09638288.2016.1161848","article-title":"Factors associated with ADL\/IADL disability in community dwelling older adults in the Irish longitudinal study on ageing (TILDA)","volume":"39","author":"Connolly","year":"2017","journal-title":"Disabil. Rehabil."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"36","DOI":"10.34172\/jcs.2022.05","article-title":"Assessment of Activities of Daily Living in Post-cardiac Care Unit Using Barthel and Katz Indexes: A Cross-sectional Study","volume":"11","author":"Khalandi","year":"2022","journal-title":"J. Caring Sci."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Yip, S.S.W., Ning, S., Wong, N.Y.K., Chan, J., Ng, K.S., Kwok, B.O.T., Anders, R.L., and Lam, S.C. (2025). Leveraging machine learning in nursing: Innovations, challenges, and ethical insights. Front. Digit. Health, 7.","DOI":"10.3389\/fdgth.2025.1514133"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1038\/s41746-024-01427-8","article-title":"Device based monitoring in digital care and its impact on hospital service use","volume":"8","author":"Jansen","year":"2025","journal-title":"NPJ Digit. Med."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"e55753","DOI":"10.2196\/55753","article-title":"Platform-Based Patient-Clinician Digital Health Interventions for Care Transitions: Scoping Review","volume":"26","author":"Backman","year":"2024","journal-title":"J. Med. Internet Res."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"1688","DOI":"10.1001\/jama.2011.1515","article-title":"Risk prediction models for hospital readmission: A systematic review","volume":"306","author":"Kansagara","year":"2011","journal-title":"JAMA"},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Alzghaibi, H. (2025). Nurses\u2019 perspectives on AI-Enabled wearable health technologies: Opportunities and challenges in clinical practice. BMC Nurs., 24.","DOI":"10.1186\/s12912-025-03343-y"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"e15400","DOI":"10.2196\/15400","article-title":"Effectiveness of Mobile Health Interventions on Diabetes and Obesity Treatment and Management: Systematic Review of Systematic Reviews","volume":"8","author":"Wang","year":"2020","journal-title":"JMIR MHealth UHealth"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"105820","DOI":"10.1016\/j.ijmedinf.2025.105820","article-title":"Effectiveness of digital health interventions for chronic conditions management in European primary care settings: Systematic review and meta-analysis","volume":"196","author":"Ambrosi","year":"2025","journal-title":"Int. J. Med. Inf."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/12\/2213\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T14:13:20Z","timestamp":1765808000000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/12\/2213"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,15]]},"references-count":60,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["medicina61122213"],"URL":"https:\/\/doi.org\/10.3390\/medicina61122213","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,15]]}}}