An evaluation of the effects of general practitioner-supported patient noncommunicable diseases control model in...

Noncommunicable diseases (NCDs) are the leading cause of death worldwide. A litmus test for China's health reform is its ability to effectively deal with NCDs. The general practitioners (GPs)-supported NCD control model was designed to address ways to effectively prevent and control NCDs population-wide. This study aimed to evaluate the GPs-supported NCD control model and its effect on China's NCD control. The model was structured with three layers of two-way relationships between patients, GPs, and specialists. The four technologies included the community-based NCD self-management model, the electronic clinical-pathways-supporting community NCD intervention, the largest regional independent medical information system engaged by the Shanghai Healthcare Cloud, and continuous and successive policy intervention. Under the influence of the model, hypertension awareness, treatment, and control were the highest in Shanghai. By 31 August 2017, 131 453 users declined to use the mobile application while 10 444 completed the type 2 diabetes mellitus (T2DM) risk assessment. By 15 August 2017, 249 000 residents had participated in early detection and screening, leading to the identification of 29 304 (11.8%) being in a prediabetic state and 24 422 (9.8%) being newly diagnosed with T2DM. From 2012 to 2016, 208 537 patients were newly identified with hypertension using Internet-connected devices and hypertension awareness increased 5.7%. After implementing the self-management interventions, patients' blood pressure was controlled at around 90% (from 2007 to 2015). This pilot model in Shanghai suggested positive social benefits and appears to have played an important role in advancing NCD control in China.