County-based integrated cardiovascular care program using risk-stratified pathways

Is this trial a fit for you?

A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.

What this trial studies

This pragmatic cluster randomized trial implements the RISIMA integrated care model through multi-level family health teams within county healthcare consortia. Clusters of township-level family doctor teams are randomized to deliver team-based care, risk-stratified care pathways, strengthened health education, financial incentives for care integration, and a supporting health information system versus usual care. The trial enrolls permanent county residents aged 40–70 with hypertension and/or type 2 diabetes who are already signed up with local family doctor teams. Outcomes include cardiovascular risk assessment, treatment adherence, control of blood pressure and glucose, and management processes during routine follow-up.

Why it matters

Who can join: the full rules

Inclusion Criteria:

1. Aged between 40 and 70 years old;
2. Patients with hypertension or diabetes;
3. Permanent residents of the county where the research is conducted;
4. Already signed up with the family doctor team in the township where the research is located.

Exclusion Criteria:

1. Unable to independently carry out the interventions required for the study;
2. Residing far from the village or township health center where the research is located, making it difficult to cooperate with visits;
3. Patients who refuse to participate;
4. Patients with comorbidities such as cancer that may interfere with the study visits or intervention effects;
5. Pregnant or lactating women

Where it's running

• Shaxian County General Hospital
  Sanming, Fujian, China Recruiting
• Luzhai County People's hospital
  Liuzhou, Guangxi, China Recruiting
• Luzhai County Traditional Medicine hospital
  Liuzhou, China Recruiting

Study contacts

• Study coordinator: Jin Prof. Xu, PhD
• Email: xujin@hsc.pku.edu.cn
• Phone: 0086-82805701

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How to take part

1. Review the eligibility criteria above with your treating physician.
2. Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
3. Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.