Hypertension and Diabetes
Conditions
Interventions
Intervention Group:In the intervention group, a smart chronic disease management app will be used for automated follow-up, real-time quality alerts, and data uploads. Data will be collected across thr
2.Process – provider adherence (e.g., completion of key steps like complication screening)
3.Implementation – user adherence (e.g., daily logins, feature usage), and patient satisfaction (CSQ-8 e-version).
Monthly online meetings will gather feedback to refine the system design.
Control group:Carry out daily usual management by the existing procedures.
Sponsors
School of Health Management, Southern Medical University,
Eligibility
Sex/Gender
All
Age
18 Years to 80 Years
Inclusion criteria
Inclusion criteria: 1.Inclusion Criteria for Primary Healthcare Institutions: (1) Institution Type: Certified by health authorities as a community health service center or township health center. (2) Service Qualifications: Authorized to provide standardized management for chronic diseases such as hypertension and diabetes, and included in the national essential public health service performance evaluation system. (3) Data Infrastructure: Equipped with an electronic health record system, with a chronic disease data completeness rate of >=70% over the past three years. 2.Inclusion Criteria for Primary Care Providers: (1) Professional Qualification: Possess a valid license as a general practitioner, public health physician, or nurse, and have at least one year of experience in chronic disease management. (2) Service Scope: Directly involved in the follow-up, assessment, or health counseling of patients with hypertension and/or diabetes. (3) Language Proficiency: Able to communicate with researchers in Mandarin and effectively interact with local residents in the local dialect. 3.Inclusion Criteria for Patients: (1) Confirmed Diagnosis: Diagnosed with hypertension and/or type 2 diabetes according to the Chinese Guidelines for the Prevention and Treatment of Hypertension and the Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes. (2) Continuity of Management: Have received standardized management for at least six months at a sample institution and are enrolled in the national essential public health service system. (3) Communication Ability: Capable of basic verbal communication.
Exclusion criteria
Exclusion criteria: 1.Exclusion Criteria for Primary Healthcare Institutions: (1)Participation in similar intelligent digital intervention studies within the past 6 months. (2)Currently involved in other pilot reforms for chronic disease management models. 2.Exclusion Criteria for Primary Care Providers: (1)Simultaneous participation in other training programs or projects that may interfere with the study results. (2)Official reprimand by administrative authorities within the past 3 years due to poor quality in chronic disease management. (3)Planned resignation or extended leave (>3 months) within the next 6 months. 3.Exclusion Criteria for Patients: (1)Presence of severe complications, such as end-stage renal disease (eGFR < 15 mL/min/1.73m²) or decompensated heart failure (NYHA Class IV). (2)Cognitive impairment, including diagnosed Alzheimer's disease, vascular dementia, or other neurological conditions that impair communication. (3)Participation in conflicting chronic disease intervention studies at the same time. (4)Planned relocation outside the jurisdiction of the current management area within the next 12 months.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Standardized management rate of hypertension patients;Standardized management rate of diabetes patients; | — |
Secondary
| Measure | Time frame |
|---|---|
| Blood pressure control rate (<140/90 mmHg) among hypertensive patients;Glycemic control rate (HbA1c<7.0% or fasting glucose<7 mmol/L);Absolute change in systolic blood pressure;Absolute change in HbA1c;Combined control rate of both hypertension and diabetes;Incidence of major cardiovascular events; | — |
Countries
China
Contacts
Public ContactXu Dong
School of Health Management, Southern Medical University
Outcome results
None listed