Chronic Disease, Chronic Disease Management, Diabetes Mellitus, Dyslipidemias, Frailty, Hypertension, Sarcopenia
Conditions
Keywords
Chronic Disease Management, Prospective Cohort, Hypertension, Diabetes Mellitus, Dyslipidemia, Cardiovascular Disease, Frailty, Sarcopenia, Aging, Healthy Aging
Brief summary
This study aims to establish the first county-level, population-based prospective cohort in Taining County, Fujian Province, China. The cohort will include at least 20,000 residents aged 18 years or older. The project will systematically collect questionnaires, physical measurements, laboratory tests, imaging data, and biological samples to build a multi-dimensional health database and biobank. Through 3-year follow-up, the study seeks to reveal the epidemiological patterns and risk factors of chronic diseases, characterize the natural course of multimorbidity and aging syndromes, and develop a comprehensive chronic disease management model suitable for rural and mountainous regions.
Detailed description
China is undergoing rapid population aging, with chronic non-communicable diseases (NCDs) becoming the leading cause of death and disability. Taining County, located in a mountainous area of Fujian Province, faces a higher-than-average aging population and a growing burden of hypertension, diabetes, dyslipidemia, and cardiovascular diseases. Early detection and standardized management remain insufficient, and healthcare resources are limited. This study will establish a prospective cohort covering ≥20,000 residents, integrating demographic, lifestyle, clinical, laboratory, and imaging data. Active follow-up will be conducted annually, complemented by passive follow-up through local healthcare and death registry systems. The study will (1) identify epidemiological features and risk factors of common chronic diseases, (2) explore multimorbidity and aging trajectories, and (3) develop a replicable Taining Model for chronic disease prevention and management at the county level. The results will provide an evidence base for public health decision-making and chronic disease control strategies in similar rural and mountainous regions.
Interventions
None listed
Sponsors
First Affiliated Hospital of Fujian Medical University
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* Age ≥18 years, male or female. * Resident of Taining County for ≥6 months and expected to remain in the county for at least the next 3 years. * Full civil capacity and able to understand study procedures. * Willing to voluntarily participate and provide written informed consent. * Able to complete baseline survey and follow-up visits.
Exclusion criteria
* Refusal to sign informed consent. * Severe psychiatric disorders or cognitive impairment preventing participation. * End-stage disease with expected survival \<1 year. * Long-term migrants (≥6 months per year outside the county), unable to guarantee follow-up. * Participation in other clinical studies that may interfere with this research.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of Major Adverse Cardiovascular Events (MACE) | Up to 36 months | Composite outcome including cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Events will be ascertained through active follow-up and confirmed using medical records and hospital discharge summaries. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Heart Failure-Related Rehospitalization Rate | Up to 36 months | Rehospitalization due to worsening heart failure among participants diagnosed with heart failure, confirmed by hospital admission records. |
| Bleeding Events | Up to 36 months | Occurrence of clinically significant bleeding events, including gastrointestinal bleeding and other major or clinically relevant non-major bleeding, identified through follow-up and medical records. |
| Health Economics Outcomes | Up to 36 months | Direct medical costs, hospitalization expenses, outpatient visit costs, medication costs, and health service utilization related to chronic disease management, collected from medical records and insurance data. |
| Incidence of Cardiovascular and Cerebrovascular Events | Up to 36 months | New onset of coronary heart disease, stroke, or heart failure, identified through follow-up visits and confirmed using medical records. |
| Cancer Incidence and Cancer-Related Outcomes | Up to 36 months | Newly diagnosed malignant tumors and cancer-related outcomes, identified through self-report and confirmed by medical records or cancer registry data. |
| All-Cause Mortality | Up to 36 months | Death from any cause, confirmed through medical records and the local death registry system. |
| Cognitive Function Outcomes | Baseline and annual follow-up (Year 1-3) | Changes in cognitive function assessed using standardized cognitive screening tools administered at baseline and during follow-up. |
Countries
China
Contacts
Primary ContactDajun Chai, MD
Backup ContactHailin Zhang
Outcome results
None listed