A community-hospital internet-based collaborative management model for secondary stroke prevention:a preliminary study for its effectiveness
10.3969/j.issn.1009-0126.2025.10.020
- VernacularTitle:基于社区-医院互联网协同管理模式对脑卒中二级预防效果的初步探索
- Author:
Jingyue LIU
1
;
Hong SUN
1
Author Information
1. 100053 北京,首都医科大学宣武医院国家老年疾病临床医学研究中心
- Publication Type:Journal Article
- Keywords:
stroke;
population health management;
community health services;
information tech-nology;
secondary prevention
- From:
Chinese Journal of Geriatric Heart Brain and Vessel Diseases
2025;27(10):1376-1380
- CountryChina
- Language:Chinese
-
Abstract:
Objective To explore the effectiveness of a community-hospital collaborative health management model in controlling cerebrovascular risk factors among the elderly population in Beijing.Methods A total of 190 elderly patients with a history of stroke or transient ischemic attack who visited the Department of Neurology at Xuanwu Hospital,Capital Medical University,between March 1 and September 1,2024,were enrolled.Then a cluster randomized trial was con-ducted based on community units to assign the participants into an intervention group(n=95,re-ceiving health management via a digital platform plus collaboration by community physician)and a control group(n=95,receiving routine outpatient care).After intervention for 6 months,the changes in awareness of the risk factors related to cerebrovascular diseases,control of related risk factors,quality of life(measured by the MOS item Short Form Health Survey)and Barthel index were observed before and after intervention.Results At 3 and 6 months after intervention,the in-tervention group had significantly lower body mass index,diastolic blood pressure,smoking and score of risk factor awareness,and higher scores in medication adherence,healthy diet,physical function,vitality,social function,and Barthel index when compared with the control group.At 6 months,systolic blood pressure was significantly lower[(129.35±21.80)mm Hg vs(138.41±22.12)mm Hg,1 mm Hg=0.133 kPa],and the score in appropriate physical activity,was signifi-cantly higher in the intervention group than the control group(73.7％vs 61.1％,P＜0.01).Conclusion A health management intervention model based on community-hospital collaboration and digital platforms can effectively promote the control of cerebrovascular risk factors and im-prove quality of life among the elderly,which providing a feasible approach for secondary stroke prevention.
