This study aims to evaluate the effect of an AI-assisted "Smart family doctor" digital health management tool on improving the control rates of hypertension, diabetes, and dyslipidemia in post-revascularization patients. A randomized controlled trial design will be used, involving approximately 10-20 hospitals and 951 participants. Eligible participants are adults aged between 18 and 80 years, post-CABG or post-PCI patients with hypertension, diabetes, and dyslipidemia.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
951
Participants will be provided "Smart family doctor", which is an AI-assisted applications with personalized interactions. The content includes, but is not limited to: (1) General educational content, covering basic health knowledge on diseases, risk factors, and treatment methods; (2) Targeted health information, such as more specific guidance on blood pressure and blood sugar control, medication adherence, exercise, and smoking cessation; (3) Personalized disease management guidance, providing tailored reminders for patients regarding medication, diet, exercise, and medical visits. Patients can also directly report their latest self-measured blood pressure, blood lipid, blood sugar levels, and medication adherence to receive treatment and medication guidance from the 'Smart family doctor'.
Participants will received 3-hour health management guidance from a health manager once a week, including guidance on healthy lifestyle, medication treatment, and rehabilitation advice.
Participants will receive usual secondary prevention management.
The control rates of hypertension, diabetes and hyperlipidemia
All cretria are meet: 1) Systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg. 2) HbA1c less than 7%. 3) LDL-C less than 1.4 mmol/L.
Time frame: 6-month
Blood Pressure Control Rate
The proportion of patients with systolic blood pressure less than 130 mmHg and diastolic blood pressure less than 80 mmHg.
Time frame: 6-month
Blood glucose Control Rate
The proportion of patients with HbA1c less than 7%.
Time frame: 6-month
Blood lipid Control Rate
The proportion of patients with LDL-C less than 1.4mmol/L.
Time frame: 6-month
Systolic blood pressure
Systolic blood pressure measured at the local site.
Time frame: 6-month
Diastolic blood pressure
Diastolic blood pressure measured at the local site.
Time frame: 6-month
Fasting blood glucose
Fasting blood glucose analyzed at central lab.
Time frame: 6-month
HbA1c
HbA1c analyzed at central lab.
Time frame: 6-month
Total cholesterol
Total cholesterol analyzed at central lab.
Time frame: 6-month
LDL-C
LDL-C analyzed at central lab.
Time frame: 6-month
HDL-C
HDL-C analyzed at central lab.
Time frame: 6-month
Triglycerides
Triglycerides analyzed at central lab.
Time frame: 6-month
Medication adherence (4-item Morisky Medication-Taking Adherence Scale)
Medication adherence measured by MMAS-4. The score range from 0 to 4. The higher score indicated the better medication adherence.
Time frame: 6-month
Coronary artery disease-related quality of life (the Seattle Angina Questionnaire)
Coronary artery disease-related quality of life assessed with the Seattle Angina Questionnaire (SAQ). The score range from 0 to 100. The higher score indicated the better coronary artery disease-related quality of life.
Time frame: 6-month
Smoking Rate
The proportion of patients who have smoked within the past month.
Time frame: 6-month
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