Hypertension, Coronary Heart Disease, Dyslipidemia, Diabetes Mellitus
Conditions
Interventions
Intervention group:Community standard disease management + Personalized health education and medication reminders + Multi-level follow-up and personalized health management.
control group:Community standard disease management
Sponsors
The First Affiliated Hospital of Xian Jiaotong University
Eligibility
Sex/Gender
All
Age
60 Years to 88 Years
Inclusion criteria
Inclusion criteria: 1) Diagnosed with two or more common cardiovascular diseases (hypertension, coronary heart disease, dyslipidemia, diabetes); 2) Aged 60 years or above; 3) Have been taking at least one medication for chronic disease for at least three months prior to inclusion in the study; 4) Able to use basic phone functions (calls, text messages, etc.); 5) Capable of independently managing their current medications; 6) Clear consciousness, able to live independently and cooperate, with stable condition; 7) Have sufficient physical ability to perform basic therapeutic exercises; 8) Have basic reading, writing, listening, and speaking abilities for effective communication; 9) Able to provide written informed consent to participate in the study.
Exclusion criteria
Exclusion criteria: 1) Recent history of serious illness (e.g., heart failure, myocardial infarction within the past 3 months, coronary artery bypass surgery or coronary revascularization, unstable angina, or uncontrolled severe arrhythmia, severe chronic obstructive pulmonary disease, cancer requiring surgery, radiotherapy, or chemotherapy); 2) Life expectancy of less than 12 months; 3) Placement in a nursing home or long-term care facility; 4) Planning to leave the community within the next 6 months; 5) Cognitive impairment or severe mental health issues; 6) Currently participating in another study related to chronic disease management.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Medication Possession Ratio;Medication Persistence;Medication adherence; | — |
Secondary
| Measure | Time frame |
|---|---|
| Blood pressure;Glycosylated haemoglobin;Low-density lipoprotein cholesterol;Triglycerides;Total cholesterol;High-density lipoprotein cholesterol;Height;Weight;NYHA classification of cardiac function; | — |
Countries
China
Contacts
Public ContactFeng Bianling
Medical Department, Xi'an Jiaotong University; The First Affiliated Hospital of Xian Jiaotong University
Outcome results
None listed