Enying Gong

Background: The one-year SINEMA trial demonstrated improved blood pressure (BP) control and reduced mortality up to 72 months after the intervention. This article aims to assess between-arm differences in mean annual cumulative BP and to explore whether the associations between cumulative BP and biofunctional outcomes differed by trial arm. Methods: Post-hoc secondary analysis of the SINEMA cluster-randomized trial, which recruited 1299 adults with stroke from 50 rural villages in Hebei, China, between 2017 and 2018. The 12-month intervention was followed by observational assessments at 72 and 84 months post-baseline. BP was measured during each face-to-face follow-up, assessed by blinded assessors at baseline, 12, 72, and 84 months. Mean annual cumulative systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP) were calculated. Biofunctional outcomes included health-related quality of life, modified Rankin Scale, activities of daily living, physical function, and cognition function. Results: Among 897 participants (mean age 62.7 years; 40.8% female) with complete data across all assessment, the intervention arm demonstrated significantly lower mean annual cumulative SBP (−2.2 mm Hg; 95% CI, −3.9 to −0.6), DBP (−1.6 mm Hg; 95% CI, −2.4 to −0.7), and MAP (−1.8 mm Hg; 95% CI, −2.8 to −0.8), not PP, compared with usual care. Significant associations between cumulative BP and biofunctional outcomes were observed in the control arm while not in the intervention arm. Interaction effects between trial arm and cumulative BP were significant for multiple outcomes, most prominently for cumulative SBP. Conclusions: The one-year SINEMA intervention was associated with lower cumulative BP burden over 72-84 months but did not improve overall biofunctional outcomes. Secondary analyses revealed that the association between cumulative BP burden and biofunctional decline differed by intervention arm, suggesting cumulative BP exposure may be an important long-term risk indicator and the intervention may modify BP-outcome relationships through mechanisms requiring further investigation.

Background: To bridge the gap between clinical guidelines and suboptimal stroke management in rural settings, we conducted an implementation trial using evidence-based, mobile health–enabled strategies to empower primary care providers in rural China. The system-integrated and digital technology–enabled model of care (SINEMA) model was shown to significantly reduce blood pressure and mortality among people with stroke in rural China. Objective: This study aimed to evaluate the cost-effectiveness of the SINEMA intervention within both the active trial and the post-trial observational periods and its budget impact for potential nationwide scalability. Methods: In the cluster-randomized implementation trial (the SINEMA trial), 50 villages were randomized to either a 1-year intervention (2017-2018) or usual care, with 1299 patients with stroke followed up until 2022-2023—6 years after the trial baseline. The incremental cost-effectiveness ratios (ICER) for systolic blood pressure reduction and quality-adjusted life year gains were estimated from a health sector perspective. Both probabilistic and deterministic sensitivity analyses were conducted to assess the robustness of the findings. Additionally, a budget impact analysis was performed from a public payer perspective to estimate the per-capita and total costs of national scale-up under 2 scenarios: a standalone intervention and integration into the existing basic public health service system. Results: The ICER per 1 mmHg systolic blood pressure reduction was $8.4 for the within-trial estimation. The ICER per quality-adjusted life year gained was $837.9 within-trial and $727.9 post-trial, both highly cost-effective relative to any commonly adopted thresholds and robust in sensitivity analyses. The first-year budget impact ranged from $115.6 million to $197.7 million in the 2 scenarios, reducing to $46.6 million to $78.7 million by year 5, with a per-capita cost of $0.03-$0.06. Conclusions: Our findings demonstrate that the SINEMA intervention was cost-effective during the trial period and remained so throughout the 6-year sustainability observation period. These results highlight the potential of adopting similar health system–integrated, mobile health–enabled strategies to enhance the management of stroke and other chronic diseases in resource-limited settings. Trial Registration: ClinicalTrials.gov NCT0318585, ClinicalTrials.gov NCT05792618; https://clinicaltrials.gov/study/NCT03185858 and https://clinicaltrials.gov/study/NCT05792618 International Registered Report Identifier (IRRID): RR2-10.3389/fneur.2023.1145562

Objective The magnitude and persistence of diseases and multimorbidity between females and males are different. This study comprehensively quantified sex differences in the onset and progression of 108 major physical and mental diseases to multimorbidity through adulthood in Chinese population. Design Quantitative analysis of real-world linked electronic health records. Setting Linked health records from 160 health facilities across primary, secondary and tertiary healthcare, comprising routinely collected electronic health records from the whole urban residents of Yichang, China between 1 January 2016 and 31 December 2019. Participants 684 455 urban residents aged 20 years and above with documented health records during the study period. Main outcomes measures The cumulative incidence, relative risks (RR) and 95% CIs, period prevalence, median age at disease diagnosis and the prevalence of multimorbidity of 108 major physical and mental diseases were computed. All analyses were stratified by sex and age groups. Results The analysis included 684 455 individuals (54.8% females, mean age: 46.9), among whom 46.3% had multimorbidity, with a higher prevalence in females (47.6%) than males (44.9%). The chronological disease map revealed stark differences between females and males, with notable lower risk of obstructive sleep apnoea-hypopnoea syndrome (OSAHS, RR: 0.03, 95% CI: 0.01 to 0.11) for young adults, oesophageal cancer (RR: 0.02, 95% CI: 0.0 to 0.17) for mid-age adults and remarkable higher risk of lupus (RR: 8.8, 95% CI: 2.7 to 29.0) for older adults of females. Males exhibited an incidence surge in hypertension, diabetes, coronary disease and chronic obstructive pulmonary disease a decade earlier than females, while females had a life-long higher prevalence in immune-mediated diseases and urinary disorders. For the new incident diseases, the manifestation of eating disorders, anaemia and urinary incontinence was recorded 20 years earlier in females; whereas, males were diagnosed with hyperuricaemia, OSAHS and schizophrenia at younger ages. Conclusions The significant variations in disease nature and trajectory between sexes underscore the urgent needs for tailored prevention strategies and appropriate health resources allocation. Sex differences in disease profile should be considered to delay disease and multimorbidity progression, ultimately promoting health equity.

Introduction: Task-shifting and task-sharing strategies show promise for managing chronic diseases especially in low-income and middle-income countries (LMICs), though their effectiveness in multimorbidity management remains unclear. This study synthesised evidence on task-shifting and task-sharing strategies globally and assessed the impact on core health outcomes in multimorbidity management. Methods: We conducted a systematic review and meta-analysis of global studies evaluating task-shifting and sharing interventions for individuals with multimorbidity. Six databases, including PubMed, Embase, Web of Science, Ovid (Medline), CINAHL and Cochrane Library, were searched for studies reporting the core outcomes of multimorbidity management in quality of life, mortality, hospitalisation, emergency department visits and symptoms of depression and anxiety. Random-effects models were used to calculate pooled effect sizes with heterogeneity assessed through subgroup and meta-regression analyses. Results: From 8471 records, 36 studies from 14 countries were included, with only 5 conducted in LMICs. Twenty-one studies, encompassing 20 989 participants, were eligible for meta-analysis. More than half of the studies involved nurses as delegates, with some sharing the tasks with health professionals and about 10% of studies involved non-health professionals, including community healthcare workers as delegates to share the responsibility in caring for individuals with multimorbidity. Most studies were multicomponent, with 16.7% addressing all guideline-recommended aspects of multimorbidity management. By pooling the findings, task-shifting and task-sharing interventions were associated with a 27% reduction in mortality (OR: 0.73, 95% CI: 0.55 to 0.97, I²=0%), a modest improvement in quality of life (standardised mean difference (SMD): 0.1, 95% CI: 0.03 to 0.17, I²=47%) and reduced symptoms of depression (SMD: 0.27, 95% CI: −0.52 to –0.02, I²=90%), but showed no significant effect on hospitalisation, emergency visits or anxiety-related symptoms. Conclusions: Some evidence, although limited in existing research, indicates the great potential of task-shifting and task-sharing strategies in supporting management of multimorbidity. Further research is needed to optimise and adopt these interventions, particularly in LMICs where evidence remains scarce. PROSPERO registration number: CRD42024526845.

BACKGROUND To bridge the gap between clinical guidelines and suboptimal stroke management in rural settings, we conducted an implementation trial using evidence-based, mobile health–enabled strategies to empower primary care providers in rural China. The system-integrated and digital technology–enabled model of care (SINEMA) model was shown to significantly reduce blood pressure and mortality among people with stroke in rural China. OBJECTIVE This study aimed to evaluate the cost-effectiveness of the SINEMA intervention within both the active trial and the post-trial observational periods and its budget impact for potential nationwide scalability. METHODS In the cluster-randomized implementation trial (the SINEMA trial), 50 villages were randomized to either a 1-year intervention (2017-2018) or usual care, with 1299 patients with stroke followed up until 2022-2023—6 years after the trial baseline. The incremental cost-effectiveness ratios (ICER) for systolic blood pressure reduction and quality-adjusted life year gains were estimated from a health sector perspective. Both probabilistic and deterministic sensitivity analyses were conducted to assess the robustness of the findings. Additionally, a budget impact analysis was performed from a public payer perspective to estimate the per-capita and total costs of national scale-up under 2 scenarios: a standalone intervention and integration into the existing basic public health service system. RESULTS The ICER per 1 mmHg systolic blood pressure reduction was $8.4 for the within-trial estimation. The ICER per quality-adjusted life year gained was $837.9 within-trial and $727.9 post-trial, both highly cost-effective relative to any commonly adopted thresholds and robust in sensitivity analyses. The first-year budget impact ranged from $115.6 million to $197.7 million in the 2 scenarios, reducing to $46.6 million to $78.7 million by year 5, with a per-capita cost of $0.03-$0.06. CONCLUSIONS Our findings demonstrate that the SINEMA intervention was cost-effective during the trial period and remained so throughout the 6-year sustainability observation period. These results highlight the potential of adopting similar health system–integrated, mobile health–enabled strategies to enhance the management of stroke and other chronic diseases in resource-limited settings. CLINICALTRIAL ClinicalTrials.gov NCT0318585, ClinicalTrials.gov NCT05792618; https://clinicaltrials.gov/study/NCT03185858 and https://clinicaltrials.gov/study/NCT05792618 INTERNATIONAL REGISTERED REPORT RR2-10.3389/fneur.2023.1145562

Background: Despite growing evidence of primary care-based interventions for chronic disease management in resource-limited settings, long-term post-trial effects remain inconclusive. We investigated the association of a 12-month system-integrated technology-enabled model of care (SINEMA) intervention with mortality outcomes among patients experiencing stroke at 6-year post-trial. Methods and findings: This study (clinicltiral.gov registration number: NCT05792618) is a long-term passive observational follow-up of participants and their spouse of the SINEMA trial (clinicaltrial.gov registration number: NCT03185858). The original SINEMA trial was a cluster-randomized controlled trial conducted in 50 villages (clusters) in rural China among patients experiencing stroke during July 2017–July 2018. Village doctors in the intervention arm received training, incentives, and a customized mobile health application supporting monthly follow-ups to participants who also received daily free automated voice-messages. Vital status and causes of death were ascertained using local death registry, standardized village doctor records, and verbal autopsy. The post-trial observational follow-up spanned from 13- to 70-months post-baseline (up to April 30, 2023), during which no intervention was requested or supported. The primary outcome of this study was all-cause mortality, with cardiovascular and stroke cause-specific mortality also reported. Cox proportional hazards models with cluster-robust standard errors were used to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs), adjusting for town, age, and sex in the main analysis model. Analyses were conducted on an intention-to-treat basis. Of 1,299 patients experiencing stroke (mean age 65.7 years, 42.6% females) followed-up to 6 years, 276 (21.2%) died (median time-to-death 43.0 months [quantile 1–quantile 3: 26.7–56.8]). Cumulative incidence of all-cause mortality was 19.0% (121 among 637) in the intervention arm versus 23.4% (155 among 662) in the control arm (HR 0.73; 95% CI 0.59, 0.90; p = 0.004); 14.4% versus 17.7% (HR 0.73; 95% CI 0.58, 0.94; p = 0.013) for cardiovascular cause-specific mortality; and 6.0% versus 7.9% (HR 0.71; 95% CI 0.44, 1.15; p = 0.16) for stroke cause-specific mortality. Although multisource verification was used to verify the outcomes, limitations exist as the survey- and record-matching-based nature of the study, unavailability of accurate clinical diagnostic records for some cases and the potential confounders that may influence the observed association on mortality. Conclusions: Despite no observed statistically difference on stroke cause-specific mortality, the 12-month SINEMA intervention, compared with usual care, significantly associated with reduced all-cause and cardiovascular cause-specific mortality during 6 years of follow-up, suggesting potential sustained long-term benefits to patients experiencing stroke.

What is already known about this topic? Uncontrolled diabetes can result in severe clinical complications, significantly increasing the risk of functional limitations in instrumental activities of daily living (IADL) and activities of daily living (ADL). What is added by this report? This study investigates the association between the Cascade of Care (CoC) for diabetes and functional limitations, providing evidence on the critical need for strengthening diabetes care to prevent functional limitations and improve quality of life. What are the implications for public health practice? The findings provide critical insights to guide public health strategies and interventions aimed at enhancing diabetes management across all stages of the CoC, with the goal of reducing functional limitations and their associated burden, ultimately improving long-term health outcomes for individuals with diabetes.

Importance: Despite evidence of the short-term benefits of multicomponent primary care–based interventions, their long-term effects are unproven.Objective: To evaluate the long-term outcomes of a system-integrated technology-enabled model of care (SINEMA intervention) for stroke management for systolic blood pressure (BP) and other outcomes among patients with stroke in China.Design, Setting, and Participants: This long-term follow-up included community-dwelling clinically stable surviving participants with stroke in an open-label cluster randomized clinical trial. Of 218 villages from Nanhe County in Hebei, China, an area with suboptimal health care resources and stroke prevalence doubling the national average, 50 villages (clusters) were recruited between June 23 and July 29, 2017, and randomized in a 1:1 ratio to an intervention or a control arm (usual care). The intervention lasted 1 year (to July 31, 2018), with a posttrial observational follow-up conducted from October 1, 2022, to August 27, 2023.Interventions: Village doctors were provided with training, performance-based incentives, technical support, and customized mobile health tools to deliver monthly follow-up to patients. Patients also received daily voice messages emphasizing medication adherence and physical activity. No intervention was requested or supported during the posttrial period.Main Outcomes and Measures: Between-arm differences in intention-to-treat analyses of individual-level changes from baseline to long-term posttrial in systolic BP (primary outcome) and stroke recurrence, diastolic BP, BP control, antihypertensive medication use and regimen adherence, and disability (secondary outcomes).Results: Among a total of 1042 stroke survivors, 44 (4.2%) were lost to follow-up and 998 (mean [SD] age at baseline: 65.0 [8.2] years; 544 [54.4%] men) completed posttrial assessment at a mean (SD) period of 66.6 (3.7) months (5.5 years) after baseline. The multicomponent intervention was associated with an estimated between-arm net reduction in systolic BP of −2.8 (95% CI, −5.3 to −0.3) mm Hg (P = .03). Most secondary outcomes showed a tendency toward lasting effects, with a notable absolute net reduction of 6.0 (95% CI, −11.3 to −0.7) percentage points and risk ratio of 0.77 (95% CI, 0.61-0.99) for stroke recurrence. In subgroup analyses, significant between-arm differences were observed among women and people with lower educational attainment, lower income, and higher use of and adherence to medications.Conclusions and Relevance: In this long-term follow-up of a cluster randomized clinical trial, the 1-year intervention was associated with significantly reduced systolic BP and stroke recurrence at 5.5 years, providing evidence of long-term health and inequity-reducing benefits and holding promise for scaling up of the intervention in resource-limited settings.Trial Registration: ClinicalTrials.gov Identifier: NCT05792618

Background: Assessing and monitoring intrinsic capacity (IC) is an effective strategy to promote healthy ageing by intervening early in high-risk populations. This review systematically analyzed the global detection rates of IC deficits and explored variations across diverse populations and data collection methods. Methods: This study was preregistered with PROSPERO, CRD42023477315. In this systematic review and meta-analysis, we systematically searched ten databases from January 2015 to October 2023, for peer-reviewed, observational studies or baseline survey of trials that assessed IC deficits among older adults aged 50 and above globally following the condition, context and population approach. The main outcome was intrinsic capacity deficits which could be assessed by any tools. Meta-analyses were performed by a random-effect model to pool the detection rates across studies and subgroup analyses were conducted by populations and data collection methods. Results: Fifty-six studies conducted in 13 countries were included in the review and 44 studies with detection rates of IC were included in the meta-analysis. The pooled detection rate of IC deficits was 72.0% (65.2%-78.8%) and deficits were most detected in sensory (49.3%), followed by locomotion (40.0%), cognition (33.1%), psychology (21.9%), and vitality (20.1%). Variations in detection rates of IC deficits were observed across studies, with higher rates observed in low- and middle-income countries (74.0%) and hyper-aged societies (85.0%). Study population and measurement tools also explained the high heterogeneity across studies. Conclusion: IC deficits are common among older adults, while heterogeneity exists across populations and by measurement. Early monitoring with standardized tools and early intervention on specific subdomains of IC deficits are greatly needed for effective strategies to promote healthy ageing.