Cardiovascular disease Circulatory System
Conditions
Interventions
Participants randomized to the intervention arm will implement an integrated and Cost-effectiveness-oriented management (CEOM) of CVD risks and harms using algorithm or model assisted: standardization
and promotion of personalized self-management based on the changing health and behavioral conditions of the individual participants under concern.
Randomization will be conducted after the baseline b
Sponsors
National Natural Science Foundation of China
Eligibility
Sex/Gender
All
Age
35 Years to 99 Years
Inclusion criteria
Inclusion criteria: Current key inclusion criteria as of 01/06/2026: Clinicians: 1. Hold a valid medical license and work full-time at the participating clinics 2. Are directly responsible for the routine management and clinical care of CVD-related patients 3. Agree to participate in the study and sign the informed consent form Patients: 1. Permanent residents (residing >6 months/year) aged 35 years or older 2. Diagnosed with hypertension, type-2 diabetes and/or established CVD (specifically coronary heart disease, stroke, or transient ischemic attack) 3. Willing and able to complete follow-up assessments _____ Previous key inclusion criteria: Clinicians: 1. Hold a valid medical license and work full-time at the participating clinics 2. Are directly responsible for the routine management and clinical care of CVD-related cases 3. Agree to participate in the study and sign the informed consent form Patients: 1. Age ?18 years 2. Have clinical diagnosis of CVD-related conditions (including hypertension, diabetes, coronary heart diseases, stroke sequelae, etc.) 3. Are permanent residents (living in the site villages for >6 months a year) 4. Are willing and able to participate and complete the pre-set surveys (e.g., EQ-5D-5L); 5) have signed the informed consent form
Exclusion criteria
Exclusion criteria: Current key exclusion criteria as of 01/06/2026: Clinicians 1. Will retire or plan to leave their current practice within the next 24 months Patients: 1. Experienced acute cardiovascular events within the past 3 months (such as acute myocardial infarction, unstable angina, or acute stroke) 2. Exhibit severe cognitive, mental, or sensory impairments that preclude smooth follow-up assessments 3. Plan to move out of the study area _____ Previous key exclusion criteria: Clinicians 1. Will retire or plan to leave their current practice within the next 24 months 2. Are participants in other interventional studies which may confound the results of the current trial Patients: 1. Plan to move out of the selected site villages within the next 24 months 2. Are participants in other interventions that may confound the results of the current trial
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Incremental Cost-effectiveness ratio (ICER) calculated using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) instrument and cost-utility survey data at baseline and at 12 and 24 months after baseline. | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Patient knowledge, attitude, and practice (KAP) regarding nutrition/diet, physical activity, smoking and alcohol abstinence, emotional and sleep problems, self-monitoring, health service use, and treatment adherence is measured using a structured questionnaire at baseline, 12 months, and 24 months 2. Systolic and diastolic blood pressure is measured using a validated automated blood pressure monitor at baseline, 12 months, and 24 months 3. Fasting plasma glucose is measured using a fasting blood test at baseline, 12 months, and 24 months 4. HbA1c is measured using a laboratory HbA1c assay at baseline, 12 months, and 24 months 5. Lipid profile (LDL-C and total cholesterol) is measured using a fasting blood lipid panel at baseline, 12 months, and 24 months 6. Body mass index (BMI) is measured using height and weight measurements at baseline, 12 months, and 24 months 7. Major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death) are measured using routinely collected medical records at baseline, 12 months, and 24 months 8. Quality of life is measured using the EQ-5D-5L questionnaire at baseline, 12 months, and 24 months 9. Medical costs, including outpatient visits, inpatient admissions, medications, and other direct medical expenditures, are measured using routinely collected healthcare expenditure data at baseline, 12 months, and 24 months | — |
Countries
China
Contacts
Public ContactShen Xingrong
Outcome results
None listed