This cluster randomized controlled trial aims to evaluate the effectiveness of a novel telemedicine-enabled integrated care model led by rural doctors in reducing cardiovascular and cerebrovascular events among elderly adults (≥65 years) at high risk of stroke in rural China. A total of 39 village clinics will be randomized to either the intervention group (digital health platform-supported integrated care) or the control group (enhanced usual care). The primary outcome is a composite of cardiovascular death, stroke, and hospitalization for heart failure or acute coronary syndrome at 36 months.
Aged 65 years or older
Rural residents with household registration or long-term residence (≥6 months/year) in the study area
High risk of stroke as defined by the National Health Commission's "8+2" stroke risk screening tool: ≥3 risk factors OR history of stroke/TIA
Willing to receive long-term health management from the assigned village clinic
Severe dementia or psychiatric disorder that prevents completion of study follow-up and assessments
Life expectancy less than 1 year (e.g., advanced malignancy, end-stage renal disease)
Currently participating in another interventional clinical trial