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

March 16, 2026 updated by: National Taiwan University Clinical Trial Center, National Taiwan University Hospital

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

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.

Study Overview

Status

Active, not recruiting

Conditions

Intervention / Treatment

Detailed Description

This is a prospective, single-center, randomized controlled trial designed to evaluate whether a nurse practitioner-led multidisciplinary team (NP-led MDT) intervention can improve the implementation rate of guideline-directed medical therapy (GDMT) and short-term clinical outcomes in hospitalized adults with multimorbidity. Multimorbidity is defined as the coexistence of two or more chronic conditions, including heart failure, hypertension, diabetes mellitus, chronic kidney disease, ischemic heart disease, and chronic obstructive pulmonary disease. Suboptimal use of GDMT is common in this population, contributing to poor clinical outcomes.

Eligible patients admitted from the emergency department to the multidisciplinary medicine ward of a tertiary medical center will be screened within 72 hours of admission. Participants will be randomly assigned in a 1:1 ratio to either the NP-led MDT intervention group or the usual care group.

In the intervention group, the NP-led MDT-comprising a nurse practitioner, physicians, and clinical pharmacists-will review each patient's diagnoses, comorbidities, baseline medications, and relevant laboratory or imaging results. Based on the latest international guidelines, the team will formulate individualized GDMT recommendations, which will be communicated to the patient's primary inpatient care team. The NP will also provide patient and caregiver education on medication adherence, potential side effects, and follow-up requirements. All final prescribing decisions will be made by the primary physician.

In the usual care group, patients will receive standard inpatient management from their primary care team without additional structured NP-led MDT intervention.

The primary outcome is the GDMT implementation rate at hospital discharge, calculated as the number of GDMT drugs prescribed divided by the number indicated according to guidelines. Secondary outcomes include all-cause readmission, emergency department visits, and mortality at 30, 60, and 90 days post-discharge, as well as selected disease-specific clinical indicators when available (e.g., left ventricular ejection fraction, HbA1c, blood pressure, LDL-C, eGFR).

Follow-up will be conducted via medical record review and telephone contact. This trial aims to provide real-world evidence on whether an NP-led MDT approach can bridge the gap between guideline recommendations and actual prescribing practices, thereby improving both medication use and patient outcomes in multimorbid inpatients.

Study Type

Interventional

Enrollment (Estimated)

178

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Taiwan
      • Taipei, Taiwan, 100
        • National Taiwan University Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  1. Age: 18 years or older
  2. Admitted to the multidisciplinary ward through the emergency department for inpatient care

  3. 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)

Exclusion Criteria:

  1. 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.
  2. 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.
  3. Unwilling to participate.
  4. Patients under the care of the study team physician on the day of hospitalization.
  5. Patients known to be economically or educationally disadvantaged

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: NP-led MDT Intervention Group
Participants receive care from a nurse practitioner-led multidisciplinary team providing individualized, guideline-based medication recommendations.
Behavioral: NP-led MDT
a nurse practitioner-led multidisciplinary team (MDT).
Active Comparator: Usual Care Group
Participants receive usual inpatient care from the primary care team without additional NP-led MDT intervention.
Behavioral: Usual Care
Participants will receive usual inpatient care provided by the primary care team.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
GDMT Implementation Rate at Hospital Discharge
Time Frame: On the day of 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

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

National Taiwan University Hospital

Investigators

  • Principal Investigator: Hsiao-Chen Chou Nurse Practitioner, National Taiwan University Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

September 2, 2025

Primary Completion (Actual)

November 24, 2025

Study Completion (Estimated)

April 1, 2026

Study Registration Dates

First Submitted

August 5, 2025

First Submitted That Met QC Criteria

August 17, 2025

First Posted (Actual)

August 22, 2025

Study Record Updates

Last Update Posted (Actual)

March 19, 2026

Last Update Submitted That Met QC Criteria

March 16, 2026

Last Verified

March 1, 2026

More Information

Terms related to this study

Other Study ID Numbers

  • 202506113RINC

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

The individual participant data will not be shared due to patient privacy concerns and institutional policy restrictions. Only aggregated study results will be made publicly available.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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