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Novel Model of Integrated Care of Older Patients With Atrial Fibrillation to Prevent Heart Failure in Rural China
Sponsor: Jiangsu Taizhou People's Hospital
Summary
This cluster randomized study aims to compare village doctor-led integrated care versus usual care to improve cardiovascular health, atrial fibrillation management, self-management adherence, and heart failure prevention among older rural patients with atrial fibrillation in China.
Key Details
Gender
All
Age Range
65 Years - 80 Years
Study Type
INTERVENTIONAL
Enrollment
1356
Start Date
2026-08-01
Completion Date
2030-07-01
Last Updated
2026-07-28
Healthy Volunteers
No
Conditions
Interventions
Village-Doctor Led Integrated Care
1. Village doctors will conduct monthly follow-up, including symptom assessment, vital-sign monitoring, medication adherence support, cardiovascular risk-factor management, health education, and referral when needed. 2. Village doctors will provide AF management based on the ABC pathway and simplified home-based exercise rehabilitation education. 3. When clinical deterioration or management difficulties occur, village doctors may use a remote care platform to obtain cardiology specialist consultation and treatment recommendations within 24 hours. 4. Village doctors will receive standardized training on AF management, anticoagulation, rate/rhythm control, and cardiovascular risk-factor management. 5. Patients will receive structured education on medication adherence, symptom monitoring, lifestyle modification, exercise rehabilitation, and recognition of warning signs.
Usual Care
Participants in the control group will receive usual chronic disease management according to the National Basic Public Health Service requirements. Usual care includes routine follow-up, general health education, medication registration, and standard referral procedures provided by local primary care providers. Participants will not receive the structured village-doctor led integrated care program.
Locations (3)
Village Clinics in Dongtai City, Jiangsu Province
Yancheng, Dongtai, China
Village Clinics in Jiangdu District, Jiangsu Province
Yangzhou, Jiangdu, China
Village Clinics in Suining County, Jiangsu Province
Xuzhou, Suining, China