This study aims to evaluate the effectiveness of a large language model (LLM)-supported, community-based integrated management model in improving cardiometabolic multimorbidity control among adults with hypertension and coexisting diabetes or dyslipidemia. Adopting an interventional study design, eligible patients will be recruited to compare the disease control indicators between LLM-assisted management and conventional management, so as to verify the effectiveness and safety of the former.
Have a designated community physician responsible for primary care who is capable of using a smartphone with stable internet access for clinical communication and LLM-assisted management;
No plan for administrative merger or restructuring within the next three years;
Located at least 2 kilometers away from adjacent participating communities (to minimize contamination between clusters).
Aged 40 years or older;
None
Parallel
LLM-Enabled Co-management
Other interventionThe intervention is a LLM-enabled, community-based integrated management strategy for cardiometabolic multimorbidity. The LLM system functions as the central intelligence layer, integrating multi-condition clinical information, delivering real-time decision support, coordinating care workflows, and facilitating continuous patient engagement. Within this LLM-enabled framework, community physicians-after standardized training-serve as the core executors of care, delivering guideline-based pharmacologic treatment, lifestyle counseling, and structured monitoring of coexisting cardiometabolic conditions. Policy-aligned performance incentives are used to support physician engagement and implementation fidelity, without altering medication access or underlying clinical protocols. The LLM-enabled intervention is implemented through the HyperMind system, an integrated platform that simultaneously supports clinicians, patients, and health-system oversight.
The between-group difference in the proportion of participants achieving simultaneous control of hypertension and either diabetes or dyslipidemia.
Simultaneous control is defined as BP \< 130/80 mmHg and at least one of the following: HbA1c \< 7.0% or LDL-C \< 2.6 mmol/L (100 mg/dL), with a stricter threshold of \< 1.8 mmol/L (70 mg/dL) for participants with cardiovascular disease(CVD).
Net changes in estimated 10-year risk for atherosclerotic CVD.
Net change in estimated 10-year atherosclerotic cardiovascular disease risk.
Proportion of participants achieving control of individual risk factors: BP < 130/80 mmHg (or < 140/90 mmHg); HbA1c < 7.0%; and LDL-C < 2.6 mmol/L (100 mg/dL) or < 1.8 mmol/L (70 mg/dL) for those with CVD.
The proportion of participants achieving target control of each individual risk factor, including blood pressure, HbA1c, and LDL-C.
Mean systolic blood pressure changes.
Mean systolic blood pressure changes of participants.
Mean diastolic blood pressure changes.
Mean diastolic blood pressure changes of participants.
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First Hospital of China Medical University
Lead sponsor
Beijing Chao Yang Hospital
Collaborator
Zhejiang University
Collaborator
Shandong Provincial Hospital
Collaborator
Cangzhou Central Hospital
Collaborator
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