Chronic Disease Management

This study aims to establish the first county-level, population-based prospective cohort in Taining County, Fujian Province, China. The cohort will include at least 20,000 residents aged 18 years or older. The project will systematically collect questionnaires, physical measurements, laboratory tests, imaging data, and biological samples to build a multi-dimensional health database and biobank. Through 3-year follow-up, the study seeks to reveal the epidemiological patterns and risk factors of chronic diseases, characterize the natural course of multimorbidity and aging syndromes, and develop a comprehensive chronic disease management model suitable for rural and mountainous regions.

The management of diabetes is of great value in reducing the risk of complications and alleviating the socioeconomic burden. Currently, the diabetes management models in China have not effectively integrated the advantages of traditional Chinese medicine (TCM) and Western medicine. They also fail to achieve intelligent and automated management, resulting in high management costs and low efficiency. Therefore, it is extremely urgent to explore a new, efficient, convenient, low - cost, and personalized long - distance, full - course, intelligent management model for diabetes that integrates TCM and Western medicine both online and offline. Based on this, our research group plans to rely on the pre - designed and developed Idata database. We will deeply integrate the diagnostic and treatment advantages of TCM constitution differentiation and Western medical examinations and laboratory tests, construct an automated follow - up path, and build an integrated online diabetes management platform for Internet hospitals, which consists of "intelligent hardware + APP + cloud services + a back - end think - tank of TCM and Western medicine experts + a back - end professional management and care team". This initiative aims to blaze a new trail in the field of long - distance, full - course, and personalized management of diabetes through the synergy of TCM and Western medicine for Chinese diabetes patients. We expect to significantly reduce the incidence of diabetes complications, remarkably improve the overall health status and quality of life of patients, and bring unprecedented positive impacts on the well - being of diabetes patients.

With the continuous development of China's economy and the improvement of medical standards, the life expectancy of the Chinese population has significantly increased. Against the backdrop of accelerating aging in China, the incidence of age-related chronic non-communicable diseases (NCDs), such as cardiovascular and cerebrovascular diseases and chronic respiratory diseases, has risen remarkably. These diseases are characterized by multiple comorbidities, high disability rates, and high mortality rates, severely compromising the quality of life of older adults, exacerbating family burdens, and straining healthcare systems. This constitutes one of the major challenges faced by aging societies. Therefore, early detection and intervention of chronic diseases in older adults are critical measures to address population aging. Comprehensive geriatric assessment (CGA), a core specialty of geriatric medicine, serves as a fundamental framework for the clinical identification of geriatric syndromes and multidisciplinary management. It is emerging as a key pathway to promote "healthy aging." Guided by this premise, this study aims to explore the application value of CGA in managing chronic diseases among older adults, with the goal of achieving full-cycle management for early detection, diagnosis, and treatment of chronic conditions in China's elderly population.

Infants with medical complexity (IMC) are a challenging population with more emergency department visits, inpatient stays, and higher healthcare costs than other children. IMC also experience lower quality emergency health care. The PI and team propose to adapt and put into place an emergency care action plan (ECAP) for IMC across four US hospitals, working directly with medical providers and families in each setting. After the tool is made available to providers and families, the PI and team will measure if the ECAP tool helps decrease the number of hospitalizations (primary research outcome) for IMC, as well as if the ECAP is feasible, acceptable, and useable for those using the ECAP over a one-year period.