Recently, the research team led by Lijing Yan from the Global Health Research Center at Duke Kunshan University published their latest findings in JAMA Open Network, titled “Primary Care–Based Digital Health–Enabled Stroke Management Intervention: Long-Term Follow-Up of a Cluster Randomized Clinical Trial”. The study, based on follow-up data over 66.6 months (5.5 years), demonstrated the significant effects of the “System-integrated technology-enabled model of care for secondary prevention of stroke” (SINEMA) in improving patient health management and reducing the risk of stroke recurrence. This model, jointly designed by the Global Health Research Center at Duke Kunshan University and multiple collaborating teams, offers a novel health management solution for stroke survivors in rural areas, filling the gap in rural chronic disease management and providing a reference for similar environments globally.
According to statistics from Global Burden of Disease Study, chronic diseases account for 86% of total deaths in China each year, with stroke being one of the leading causes of death. Stroke not only leads to millions of deaths and long-term disabilities annually but also imposes a significant economic burden on patients’ families and society. The high risk of recurrence and the expensive treatment costs, especially for rural families, create heavy economic pressure. Additionally, rural patients lack health education and management tools, further increasing the risk of disease recurrence. The combination of these issues makes the long-term management of stroke an important issue that public health systems urgently need to address.
“The long-term health management of stroke patients faces multiple challenges. As a high-quality randomized controlled trial, the findings of the SINEMA project provide strong scientific evidence for the field of chronic disease management. This study fills the global research gap in the long-term management of stroke survivors, especially in resource-limited rural environments, offering important references for designing and implementing efficient, low-cost interventions,” said Lijing Yan, the project leader and professor at the Global Health Research Center at Duke Kunshan University.
Innovative Comprehensive Intervention Approach
“The SINEMA design is a comprehensive intervention model primarily composed of three main components: empowering rural doctors, supporting patient self-management, and multi-level community and family involvement. The management of chronic diseases is a long and complex process and relying solely on doctors or patients themselves is far from sufficient. We also applied mobile health technology in the intervention design, which is crucial for enhancing intervention efficiency and establishing effective communication with patients,” said Jie Tan, the first author and researcher at the Global Health Research Center at Duke Kunshan University.
- Empowering Rural Doctors: Enhancing Primary Healthcare Capacity
Rural doctors play a vital role in the rural healthcare service system. The SINEMA project helps rural doctors acquire key skills in stroke management through customized training, including how to monitor blood pressure, provide medication guidance, and educate on healthy lifestyles. Additionally, the project equips doctors with a mobile health application to help them record patients’ health data and develop personalized intervention plans based on individual patient circumstances. To encourage doctors’ active participation in the intervention and ensure service quality, the project has introduced a performance-based reward mechanism. - Patient Self-Management Support: Enhancing Health Awareness and Compliance
In rural areas, patients often lack the necessary knowledge and tools for disease management. The SINEMA intervention provides daily automated voice reminders that offer easy-to-understand medication guidance, health advice, and lifestyle education, helping patients establish long-term health management habits and significantly improving medication compliance. Furthermore, with technological support, patients can better understand their health status and achieve health goals with the assistance of their doctors. - Community and Family Support: Forming a Multi-Level Health Security System
By mobilizing family members and community resources, the project provides patients with emotional support and behavioral supervision. This multi-level support system helps patients overcome psychological and behavioral barriers in health management, while also ensuring the long-term effectiveness of the intervention measures.
Reducing Stroke Recurrence Risk and Improving Long-Term Health Outcomes
The SINEMA intervention was launched in Nanhe County, Hebei Province, in 2017, covering 50 villages and recruiting 1,299 stroke survivors to participate in a randomized controlled trial. The intervention lasted for one year, and multiple follow-ups were conducted after the intervention to assess its long-term effects. This study is based on follow-up data over 66.6 months (5.5 years), and the interim follow-up results further confirm the significant effects of the SINEMA project in improving patient health management and reducing the risk of stroke recurrence. The main findings include:
- Significant Effect on Blood Pressure Control
The average systolic blood pressure (SBP) of patients in the intervention group was 2.8 mmHg lower than that of the control group (95% confidence interval: -5.3 to -0.3, P=0.03). Although slightly weaker than the -2.9 mmHg at the one-year follow-up, this long-term blood pressure improvement still has significant importance for the prevention of stroke recurrence. - Significant Reduction in Stroke Recurrence Rate
The stroke recurrence rate in the intervention group was 23% lower than that of the control group (risk ratio of 0.77; 95% confidence interval: 0.61 to 0.99), with an absolute risk reduction of 6 percentage points. This result further proves the effectiveness of comprehensive intervention measures in reducing the risk of stroke recurrence, providing strong support for future secondary prevention strategies. - Improvement in Health Equity
The study found that the SINEMA intervention was more effective for female patients, those with lower education levels, and those with lower family incomes. These vulnerable groups, through project support, narrowed the health gap with people of higher socioeconomic status, further demonstrating the importance of health equity in chronic disease management.
Looking to the Future: Expanding and Deepening Research
The SINEMA intervention has improved patient health management levels by enhancing the capabilities of rural doctors and introducing technological assistance, effectively narrowing the health gap between urban and rural areas. Its successful experience provides valuable insights into the formulation of public health policies, especially in how to use technology and primary healthcare services to optimize chronic disease management. This achievement is not only of great significance to rural areas in China but also provides a reference model for chronic disease management in other developing countries and regions.
In the future, the research team plans to conduct a 10-year end-point assessment after the baseline in 2027, to further explore the long-term health benefits, sustainability, and economic feasibility of the intervention, providing valuable practical experience and policy insights for similar environments globally.
The SINEMA project (System Integrated Nursing Model with Electronic Assistance) was launched on June 23, 2017, in Nanhe District, Xingtai City, Hebei Province, China. This is an area with scarce medical resources and a stroke incidence rate twice the national average. The project is led by Duke Kunshan University and is conducted in collaboration with multiple organizations, including the Chinese Academy of Medical Sciences, the UK Medical Research Council (MRC), the National Natural Science Foundation of China (NSFC), and the National Key Research and Development Program of China. It provides scientific support for exploring effective models of stroke management in resource-limited rural areas.
By Ruitong Li, Jie Tan, Wuyue Qian, Yijie Nan
To download the NIP report, visit: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2828032
