Community-based prevention and treatment of cardiovascular diseases

Sheng-Shou HU,The Writing Committee of the Report on Cardiovascular Health and Diseases in China

Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing,China

ABSTRACT The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China.This is the third section of the report with a specific focus on community-based prevention and treatment of cardiovascular diseases (CVD).This section of the report underscores the importance of initiatives outlined in the ＂Healthy China 2030 Plan,＂ emphasizing the comprehensive prevention and control strategy for chronic diseases.A key aspect of this plan involves the establishment of national demonstration areas aimed at comprehensive prevention and control of chronic diseases.By 2020,488 such areas had been set up across China,surpassing the initial target and covering a significant proportion of counties and districts.The report highlights the successful implementation of these strategies in Lishan district,Anshan city,where demonstration areas for comprehensive prevention and control of chronic diseases were launched in 2013.Over the course of seven years,the number of healthy units increased substantially,leading to improvements in managing risk factors for CVD among residents.Significant reductions in prevalence rates of overweight,obesity,smoking,passive smoking,and drinking were observed,along with the development of healthier behaviors among residents.Similarly,Qiaokou district in Wuhan City,designated as a national demonstration area in 2014,implemented comprehensive public health promotion initiatives.Notably,special clinics for hypertension intervention were established,contributing to an increase in self-reported rates of hypertension,a slight decrease in prevalence,and a remarkable improvement in the control rate among treated patients.Overall,these efforts underscore the effectiveness of community-based approaches in driving positive health outcomes and advancing the comprehensive prevention and control of chronic diseases,particularly cardiovascular diseases,in China.

NATIONAL DEMONSTRATION AREA PROJECT FOR COMPREHENSIVE PREVENTION AND CONTROL OF CHRONIC DISEASES

Objectives of National Health Laws,Policies,and Planning

The cardiovascular diseases (CVD) prevention and control action ranks first among the special action for five major diseases of the “Healthy China Action(2019-2030)”.[1]In June 2020,the Basic Medical and Health Promotion Law of the People’s Republic of China was officially implemented,providing a legal basis for health promotion,basic public health services,and basic medical services closely related to chronic disease prevention and control.[2]In March 2022,the Physician Law of the People’s Republic of China came into effect,providing legal protection for all physicians to carry out medical activities and assist patients.[3]

In March 2021,the 14thFive Year Plan for National Economic and Social Development of the People’s Republic of China and the Outline of Long-term Goals for 2035 proposed at an unprecedented height the strategic position of prioritizing the development of safeguarding people’s health.[4]Adhering to the policy of putting prevention first,deepening the implementation of the Healthy China Action,improving national health promotion policies,and providing comprehensive and lifelong health services to the people will greatly promote the implementation of CVD prevention and control strategies for the entire population.In April 2022,the General Office of the State Council issued the “14th Five Year Plan”for National Health (hereinafter referred to as the“14th Five Year Plan”).Among the nine indicators in the fields of “health level”and “healthy lifestyle”,six indicators were directly related to CVD prevention and control (Table 1),and higher expectations were put forward for per capita life expectancy,that is,to reach 80 years old or above by 2035.[5]

The 14thFive Year Plan emphasizes the popularization of healthy lifestyles.In terms of strengthening health promotion and education,the 14thFive Year Plan proposes to encourage medical institutions and medical personnel to carry out health promotion and education,and further develop the construction of health promotion hospitals;carry out in-depth publicity and popularization of health knowledge to improve residents’ health literacy;carry out the construction of healthy counties and districts,with the proportion of national and provincial healthy counties and districts not less than 40%;continue to promote special actions for health promotion in primary and secondary schools,deepen the reform of school health education,effectively ensure the time of school health education,and improve the teaching effect of health education.In terms of comprehensively implementing the nationwide healthy lifestyle action,the 14thFive Year Plan proposes to promote special actions such as “three reductions and three health benefits”(salt reduction,oil reduction,sugar reduction,healthy oral cavity,healthy weight,and healthy bones);implement the national nutrition plan and healthy diet action,carry out tobacco control action,vigorously promote the construction of a smoke-free environment,continue to promote tobacco control legislation,strengthen alcohol restriction health education,control alcohol overuse,and reduce alcohol abuse.In carrying out the national fitness campaign,the 14thFive Year Plan proposes to deepen the integration of physical fitness and health,hold demonstration activities with the theme of national fitness,advocate the concept of active health,and popularize sports to promote health knowledge;build a higher level of public service system for national fitness,promote the opening and sharing of public sport venues and school sport venues,and improve the coverage of convenient fitness venues such as fitness trails;ensure adequate school physical education and extracurricular exercise time;implement the national physique monitoring system,promote cooperation between national physique monitoring stations and medical and health institutions,and establish scientific fitness clinics in conditional medical and health institutions;provide physical fitness guidance for special populations,strengthen non-medical health interventions,establish and improve a sport prescription database,and promote the application of prescriptions.

The 14thFive Year Plan strengthens comprehensive prevention and control of chronic diseases.In implementing comprehensive prevention and control strategies for chronic diseases,the 14thFive Year Plan requires strengthening the construction of national comprehensive prevention and control demonstration area for chronic diseases (hereinafter referred to as “demonstration area”),with a coverage rate of 20%by 2025.The 14thFive Year Plan also proposes to improve the comprehensive prevention and treatment capabilities of major chronic diseases such as CVD;strengthen prevention,early screening,and comprehensive intervention,and gradually incorporate appropriate technologies for early diagnosis and treatment of eligible chronic diseases into the diagnosis and treatment routine according to regulations;actively promote blood pressure surveys in hospitals below the second level medical hospitals and communities for outpatients over the age of 35 years at their first visit;carry out CVD opportunistic screening among clinic patients;promote the establishment of free blood pressure measuring points in government agencies,enterprises,institutions,and public places,and guide the public to conduct regular testing;promote the co-management of “three highs”(hypertension,hyperglycemia and hyperlipidemia),and the stand-ardized management rate of hypertension and type 2 diabetes patients at the communities should reach more than 65%.In terms of innovative emergency rescue services,the 14thFive Year Plan requires optimizing the pre-hospital medical emergency network,continuing to promote the construction of centers for chest pain and stroke,providing patients with green channels for medical treatment and integrated comprehensive treatment services,and improving the quality and efficiency of medical treatment for major acute diseases;improving the intelligent scheduling system,promoting the effective connection between the pre-hospital medical emergency network and the hospital emergency,realizing the pre-hospital and in-hospital sharing of patient information,and building a fast,efficient,and fully covered emergency and critical medical treatment system.As for the integration of medicine and prevention,the 14thFive Year Plan requires that relying on the national basic public health service projects,taking hypertension and type 2 diabetes as the starting point,implementing the project to improve the ability of the integration of medicine and prevention of chronic diseases in urban and rural communities,training 1-2 compound backbone personnel with medical and prevention management capabilities for each township health center and community health service center,exploring the establishment of a team of grassroots doctors as the performance assessment outcomes and resident satisfaction oriented assessment system;promoting the organic integration of prevention,treatment,nursing,and rehabilitation,and forming an integrated health management service of proactive prevention before illness,scientific management after illness,and uninterrupted follow-up services.

The 14thFive Year Plan attaches greater importance to the patriotic health movement.In comprehensively promoting the construction of healthy cities and towns,the 14thFive Year Plan proposes to create a number of healthy city models and create a healthy supportive environment;carry out the construction of healthy counties,towns,and cells (health villages,health communities,health enterprises,health institutions,health schools,health promotion hospitals,and healthy families),and cultivate a number of characteristic models for the construction of healthy cells.In terms of innovative social mobilization mechanisms,the 14thFive Year Plan requires that patriotic health campaigns be closely combined with the prevention and control of infectious diseases and chronic diseases.Through activities such as the Patriotic Health Month,efforts should be made to increase science popularization and promote a civilized,healthy,natural lifestyle.

In August 2022,the report of the 20thNational Congress of the Communist Party of China (hereinafter referred to as the “Report of the 20thNational Congress”) first mentioned that people’s health is an important symbol of national prosperity,and stressed once again the need to give priority to the protection of people's health and improve people's health promotion policies;the report specifically stated that prevention should be given priority,health management of major chronic diseases should be strengthened,and grassroots capacity for disease prevention,treatment,and health management should be improved;the Healthy China Action and Patriotic Health Campaign should be carried out deeply to advocate a civilized and healthy lifestyle.[6]

Overview of National Demonstration Area for Comprehensive Prevention and Control of Chronic Diseases

“Healthy China 2030 Plan”demands implementing the comprehensive prevention and control strategy of chronic diseases and strengthening the construction of national demonstration areas for comprehensive prevention and control of chronic diseases.[7]In January 2017,the General Office of the State Council issued the “Medium and Long Term Plan for Prevention and Control of Chronic Diseases in China (2017-2025)”,proposing that the coverage of national demonstration area will reach 15% and 20% in 2020 and 2025,respectively.[8]As of 2020,488 national demonstration areas had been established in 31 provincial administrative units across China,covering 17.1% of all counties and districts.After 10 years of unremitting efforts,a multisectoral cooperation mechanism has been established within the demonstration areas,but the durability and effectiveness of the cooperation still need to be improved.[9]In 2021,in order to effectively play the exemplary and leading role of the demonstration area in implementing the Healthy China Action and promoting the improvement of the health level of the population,the National Health Commission organized a review of the demonstration areas to further strengthen its working mechanism of “government led,departmental collaboration,mobilization of society,and participation of the whole people”.[10]As an important basis of “implementing the comprehensive prevention and control strategy of chronic diseases”in the “14thFive Year Plan”,the construction of national demonstration areas is driving the fundamental transformation of CVD prevention and control strategy from high-risk individuals to the whole population.

Cases of National Demonstration Area for Comprehensive Prevention and Control of Chronic Diseases

Anshan city: building a health unit to promote the health of the whole population

The construction of demonstration areas for comprehensive prevention and control of chronic diseases in Lishan district of Anshan city was launched in 2013,adhering to the principle of government leadership,multi-department collaboration,and whole society participation,providing chronic disease prevention and management services that are oriented to the entire population and cover the entire life cycle,forming a disease prevention model of early prevention,early detection,and early diagnosis for chronic diseases,and promoting people to consciously develop healthy behaviors and lifestyles.[11]During 2013-2020,the number of healthy units (such as healthy schools,healthy canteens,healthy restaurants,healthy theme parks,healthy footpaths,healthy huts,healthy communities and the like) increased by 59%,from 73 to 116.The healthy units and other achievements improved the management of risk factors for CVD among residents.The prevalence rates of overweight,obesity,smoking,passive smoking and drinking decreased significantly by 15.00%(36.79%vs.31.27%),40.30% (16.90%vs.10.09%),35.87% (30.63%vs.19.52%),50.95% (75.12%vs.36.85%) and 53.13% (32.73%vs.15.34%),respectively.Healthy behaviors have been developed in the 7 years.The proportions of residents who used salt limiting spoon and oil control kettle in daily life and who needed healthcare information on chronic diseases increased from 3.22%,1.26%,and 48.65% to 15.34%,12.95%,and 65.74%,respectively.The prevalence rates of hypertension and DM decreased from 34.69% and 16.76% to 23.51% and 8.96%,respectively.The life expectancy was prolonged by 1.57 years (78.00vs.79.57 years).

Wuhan city: standardizing hypertension management to promote cardiovascular health

In 2013,Qiaokou district of Wuhan city carried out a sampling survey of hypertension among residents aged ≥ 18 years,and was chosen as the third batch of national demonstration area in 2014.In 2015,Qiaokou district organized experts in the fields of public health,clinical diagnosis and treatment,physical examination,information technology,and other fields within its jurisdiction to establish a health management expert team.By comprehensively promoting nationwide health management services,a mechanism of cooperation was set up for management of health by disease prevention and control centers,hospitals and community medical institutions.Special clinics for intervention of hypertension were opened in Qiaokou district by 10 community health centers and private hospitals according to their own characteristics.Fitness venues,health trails,and bike paths within 10 min of walking distance were built in each community.In 2017,a regional sampling survey was conducted again,and the results showed that the self-reported rate of hypertension increased from 16.88% in 2013 to 23.71%in 2017,the prevalence decreased from 33.71% to 33.54%,and the control rate among treated patients increased from 22.22% to 51.09%.[12]

Summary

The 14thFive Year Plan puts forward clear and detailed work requirements for community prevention and control of chronic diseases,and the construction of demonstration area is currently the most powerful work basis.Guided by the work philosophy of centering on people’s health,government led,departmental collaboration,mobilization of society,and participation of the whole people,the demonstration area will certainly play a greater exemplary and leading role in implementing the Healthy China Initiative and promoting the improvement of the health level of the population.Report of the 20thNational Congress proposes new requirements for the prevention and treatment of major chronic diseases,and the construction of the demonstration area is expected to play a greater role in improving the community capacity for disease prevention and treatment and health management.

TYPICAL CASES OF CARDIOVASCULAR DISEASES PREVENTION AND TREATMENT IN COMMUNITIES

The “Outline of the Healthy China 2030 Plan”emphasizes improving the contracted family doctor services in the innovative supply model of medical and health services,comprehensively establishing a mature hierarchical diagnosis and treatment system,forming a reasonable medical order of first diagnosis at the grassroots level,two-way referral,linkage between upper and lower levels,and separation of urgent and slow treatment,and improving the treatment-rehabilitation long-term care service chain.Based on the above requirements,a variety of new models for CVD prevention and control have been developed in communities.

“Patient-Centered”Diagnosis and Treatment Model for CVD in Communities

Based on the current situation of CVD prevention and management in primary care,the First Affiliated Hospital of China Medical University adopted the literature research and expert judgement method to construct appropriate CVD prevention and management technologies applicable to general practitioners and their teams in communities.By consulting 24 experts in the fields of general medicine,cardiovascular,public health,and mental health in the four major economic centers in eastern,central,western,and northeastern China,25 patient-centered appropriate technologies for CVD prevention and management in primary care were constructed.The comprehensive evaluation showed that the top three were history collection and physical examination,recognition and referral of acute patients,and patient reception in general practice.The model provides technical support to general practitioners and their teams for better care of CVD in their practice.[13]

“1+1+1”Type of Contracted Family Doctor Services

Xuhui district of Shanghai implemented the“1+1+1”type of contracted family doctor services for patients after percutaneous coronary intervention (PCI) and evaluated the management effectiveness of this model (i.e.,residents freely choose to sign a family doctor at a community health service center,a district level medical institution,and a municipal level medical institution).A total of 127 patients with initial PCI undergoing post-PCI followup at a community health service center were randomly divided into an intervention group (n=64,“1+1+1”type of contracted family doctor services)and a control group (n=63,routine follow-up).After 2 years of follow-up,the control rates of blood pressure,blood glucose,and blood lipid in the intervention group were higher than those in the control group.The incidence of angina pectoris in the intervention group and the 10-year risk of ischemic CVD in male patients were lower than those in the control group.The study implied that “1+1+1”type of contracted family doctor services can better control the risk factors of CAD in patients after PCI,reduce the incidence of angina pectoris,and decrease the 10-year risk of ischemic CVD in male patients.[14]

Comprehensive Prevention and Management Model of Cardiovascular Risk

The Cardiopulmonary Prevention and Rehabilitation Center of Zhanlan Road Hospital,Xicheng District,Beijing,took the comprehensive management of cardiovascular risk in cardiac rehabilitation as the overall design idea,evaluated the effectiveness and feasibility of the comprehensive management of cardiovascular risk based on detailed lifestyle intervention for prediabetes patients,and explored the management scheme for prediabetes patients suitable for the community.In 2019,96 prediabetes patients screened by questionnaire scoring combined with oral glucose tolerance test were randomly divided into a comprehensive cardiovascular risk management group (detailed lifestyle intervention) and a health education group (only oral health education).After 1 year follow-up,compared with the health education group,the comprehensive management group significantly increased the score of the cardiovascular risk factor knowledge questionnaire (17.62 ± 2.30vs.22.02 ± 2.05 points),and significantly decreased the levels of fasting blood glucose [(6.38 ± 0.41) mmol/Lvs.(6.12± 0.41) mmol/L] and blood glucose 2 h after glucose loading (8.34 ± 0.65vs.8.00 ± 0.61 mmol/L).The peak oxygen uptake (19.65 ± 5.17vs.22.24 ± 5.00 ml/kg/min) and peak power (121.51 ± 39.09vs.137.31 ± 36.02 W) were significantly increased.It is suggested that the comprehensive management of cardiovascular risk based on lifestyle intervention is an effective management method for patients with prediabetes,which can significantly reduce blood glucose level,improve exercise function,and have positive significance in preventing diabetes.[15]

Participants with CAD were recruited between August and November 2019 in two community settings in Hengyang city,Hunan province,China.This cluster randomized controlled trial aimed to investigate the effect of a nursing intervention based on Cox’s interaction model of client health behaviour on health outcomes and secondary prevention of CAD.A total of 77 participants were randomly divided into intervention group (37 cases) and control group (40 cases).Participants in the intervention group received a nursing intervention based on Cox’s interaction model of client health behaviour and routine health education,while those in the control group received routine health education only.The results showed that after 12 weeks,compared with the control group,the intervention group significantly improved its questionnaire scores in lifestyle,symptoms,emotional cognition,emergency response,disease knowledge,and medication compliance.The systolic blood pressure (128.45 ± 15.65vs.138.64 ± 18.14 mmHg),BMI (21.92 ± 2.30vs.22.99 ± 1.76 kg/m2),and LDL-C (2.61 ± 0.40vs.2.91± 0.60 mmol/L) in the intervention group were significantly lower than those in the control group.It is suggested that secondary prevention management based on Cox’s interaction model of client health behaviour is an effective method for patients with CAD,which can improve the prognosis of patients with CAD and promote the formation of their healthy behaviours.[16]

“PLSP”Community Integrated Management Model

In order to further improve the standardized management of diabetes patients,peer leader-support program (PLSP) was implanted among patients with diabetes in 3 communities in Anhui.Diabetes patients who can adhere to both medication and behavioral management regimens,and have experience in teaching and nursing serve as leaders.They assist other diabetes patients in their daily management,provide them with social and emotional support,and cooperate with the community health service center to carry out health education for patients.More than 240 participants with diabetes were selected in each community and divided randomly into PLSP group and control group.A total of 229 participants completed the 6-month follow-up and were included in the final analysis.Significant interactions between condition and time lapse from baseline to follow-up indicated greater favorable changes for PLSP participants for diabetes knowledge (+0.84vs.-1.49),self-efficacy (-0.9vs.-3.8),BMI (-0.6vs.+0.5kg/m2),systolic blood pressure (-8vs.+1 mmHg) and diastolic blood pressure (-3.4vs.-0.4 mmHg),fasting glucose (-0.92vs.+0.28 mmol/L),and 2-h post-prandial glucose(-1.1vs.+0.1 mmol/L).The Anhui Provincial Health Bureau has extended the PLSP model to other communities and to CVD prevention and management.It is suggested that the “PLSP ”community comprehensive management model can better control blood pressure and blood glucose,improve self-efficacy,and have the potential for further promotion.[17]

Management Mode Based on Information Construction

In order to effectively manage patients with atrial fibrillation,Shanghai Zhongshan Hospital established a clinical decision support system (CDSS)based on artificial intelligence to assist general practitioners in comprehensive management of patients with atrial fibrillation.The system uses the hospital information system (HIS) as the carrier,and the CDSS supported by computer algorithms helps general practitioners make quick,individualized,and correct clinical decisions by combining patient data with guidelines and using evaluation tools in brief consultations.Currently,a one-year pilot study using CDSS has been completed in 53 patients with atrial fibrillation,and it has been found that the reasonable anticoagulation ratio in the intervention group is significantly increased compared to the control group.The research team has decided to conduct a larger scale study to further evaluate whether the promotion of CDSS will improve primary health care services for patients with atrial fibrillation and bring benefits for patients,physicians,and health economics,and promote the management ability of general practitioners in atrial fibrillation.[18]

Summary

Through various exploration and practice of CVD management models,personnel of primary medical and health institutions have summarized more and more work experience in CVD screening,comprehensive evaluation,and management that is suitable for community development,which has played a positive role in improving the CVD management level and efficiency of general practitioners,enabling more CVD patients to receive long-term,continuous,and effective health management in the community.It is of great significance for improving the quality of life and long-term prognosis of CVD patients in China.