Mehmood Safia, Kazmi Nashwa, Khan Sadia
Public Health, Meri Sehat Pvt. Ltd., Karachi, PAK.
Epidemiology of Cancer and Environmental Exposures (EPICENE) U1219, Bordeaux School of Public Health (ISPED) Bordeaux Population Health Center, Bordeaux, FRA.
Cureus. 2025 Mar 14;17(3):e80577. doi: 10.7759/cureus.80577. eCollection 2025 Mar.
This case report evaluates the efficacy of a personalized, multidisciplinary chronic care management (CCM) program aimed at improving health outcomes for individuals with polychronic conditions within Pakistan's under-resourced healthcare system. Implemented in November 2023, the intervention was designed to help two office employees newly diagnosed with type 2 diabetes and associated comorbidities, such as hypertension and obesity. Over six months, the participants engaged in a structured program that included teleconsultations, personalized care plans, and biweekly follow-ups through a social media application. The 'care team,' comprising doctors, nutritionists, wellness coaches, and care attendants, facilitated these interactions. Specific outcomes included a reduction in hemoglobin A1c (HbA1c) from 15% to 5.4% with a 26.3 kg weight loss for Participant 1 and a 3 kg weight loss with a decrease in HbA1c from 6.5% to 6.1% for Participant 2. This report highlights the potential of comprehensive, integrated, and patient-centered diabetes management to enhance glycemic control and weight management in settings burdened by high disease prevalence and limited healthcare resources.
本病例报告评估了一项个性化、多学科慢性疾病管理（CCM）项目的效果，该项目旨在改善巴基斯坦资源匮乏的医疗体系中患有多种慢性疾病的个体的健康状况。该干预措施于2023年11月实施，旨在帮助两名新诊断出患有2型糖尿病及相关合并症（如高血压和肥胖症）的办公室员工。在六个月的时间里，参与者参与了一个结构化项目，该项目包括远程会诊、个性化护理计划以及通过一款社交媒体应用程序进行的每两周一次的随访。由医生、营养师、健康教练和护理人员组成的“护理团队”推动了这些互动。具体成果包括：参与者1的糖化血红蛋白（HbA1c）从15%降至5.4%，体重减轻26.3千克；参与者2体重减轻3千克，HbA1c从6.5%降至6.1%。本报告强调了在疾病患病率高且医疗资源有限的环境中，全面、综合且以患者为中心的糖尿病管理在改善血糖控制和体重管理方面的潜力。
