基于数智平台的心血管病立体联动管控的理论框架与实践路径OA

With the continuous rise in the incidence of cardiovascular diseases(CVDs),their high disability and mortality rates pose a significant challenge to China's public health system.Against the backdrop of uneven regional distribution of medical resources,weak post-discharge management,and limited primary care capacity,exploring systematic and intelligent approaches for prevention and control has become imperative.In view of the current healthcare system in China,this study integrates artificial intelligence(AI)and information technology to construct a theoretical framework for multi-level,integrated CVDs management,centered on medical quality improvement,extension of post-discharge services,and strengthening of primary care capacity.A unified digital intelligence platform was developed to support practical implementation,integrating heterogeneous multi-source data and encompassing four core functional modules:medical quality control,hospital management and research data services,full-cycle post-discharge management,and primary care chronic disease management.The platform enables an intelligent service model and supports multi-dimensional effectiveness evaluation.Drawing on both domestic and international CVDs prevention and control experiences,corresponding strategies for wider implementation are proposed.This study aims to provide theoretical support and practical pathways for building a full-process,intelligent CVDs management system,promoting the transformation of chronic disease management in China toward efficient coordination and intelligent integration,and offering sustainable solutions for achieving the objectives of the Healthy China strategy.