County Medical Community-Based Care Model Using Cardiovascular Risk Stratification for Patients with Hypertension and Diabetes in a Cluster Randomized Trial

What this Trial Is About

Researchers are evaluating the RISIMA model, an integrated care approach for patients aged 40 to 70 with hypertension andor type 2 diabetes. This model focuses on cardiovascular disease CVD risk assessment, treatment, and management through a community-based healthcare consortium. The trial aims to assess how well this risk-stratified integrated care model works compared to standard care in improving patient outcomes related to cardiovascular risk. The study compares two groups one receiving usual public health services including quarterly follow-ups and annual physical exams, and the other receiving the RISIMA model. This integrated model includes team-based care by family health teams, a risk-stratified care pathway based on CVD risk scores, enhanced health education sessions, financial incentives for care integration, and a supporting health information system. The intervention is delivered as a package with tailored management plans according to patients cardiovascular risk levels. Participants will be involved for at least 12 months, during which researchers will monitor outcomes such as the 10-year CVD risk score, blood pressure control, cholesterol, fasting blood sugar, and cardiovascular event rates. The study also evaluates cost-effectiveness. Participants will attend regular follow-ups, education sessions, and risk assessments, with data collected via a health information system that supports care coordination and performance evaluation.

County Medical Community-based, Cardiovascular Risk Stratified Integrated Care Model: a Pragmatic Cluster Randomised Control Trial