Abstract
BACKGROUND: Cardiovascular and cerebrovascular diseases (CVDs) present a significant challenge in the realm of chronic disease management in China. The objective of this study is to assess the efficacy of a health management model rooted in a three-tier prevention and control system for CVDs. METHODS: From August 2020 to September 2020, this study enrolled 2033 CVDs patients from 105 villages across three townships in central China. All participants underwent a 12-month health management involving monitoring, risk assessment, health education, and interventions. The primary endpoint focused on recurrence and exacerbation, while secondary outcomes encompassed health economic indicators, awareness of prevention and control knowledge, risk factor, lifestyle behavior. Data analysis was conducted using generalized estimating equation models. RESULTS: After 1 year of follow-up, the odds of recurrence and exacerbation decreased significantly compared to the baseline [odds ratio (OR) 0.30, 95% confidence interval (CI): 0.26, 0.35], accompanied by reduced hospitalization frequency [mean difference (MD) -0.61, 95% CI: -0.66, -0.56] and a monthly average reduction in medication costs (MD, -69.80, 95% CI: -104.55, -35.05). Moreover, patients' awareness of CVDs prevention and treatment knowledge markedly improved (P < 0.01). Diastolic blood pressure, blood lipid and plasma glucose levels, anxiety and depression, lifestyle behavior all demonstrated significant enhancements from baseline levels (P < 0.01). Crucially, health management did not result in an increased abnormality rate of safety indicators. CONCLUSIONS: The health management model, grounded in a three-level prevention and control system, showed potential applicability in reducing recurrence and exacerbation, easing healthcare economic burden, boosting awareness of prevention and treatment, and positively influencing risk factors. Additional multicenter and long-term studies are necessary to validate these findings and support broader implementation of this model. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR) ChiCTR2000032243 (24/04/2020) ( https://www.chictr.org.cn/showproj.html?proj=52395 ).