BACKGROUND: China is vigorously promoting the health management of chronic diseases and exploring digital active health management. However, as most medical information systems in China have been built separately, there is poor sharing of medical information. It is difficult to achieve interconnectivity among community residents' self-testing information, community health care information, and hospital health information, and digital chronic disease management has not been widely applied in China.
OBJECTIVE: This study aimed to build a digital health platform and improve the effectiveness of full-cycle management for community chronic diseases through digital active health management.
METHODS: This was a single-arm pre-post intervention study involving the development and use of a digital health platform (2-year intervention; 2020 to 2022). The digital health platform included the "i Active Health" applet for residents and the active health information system (cardio-cerebrovascular disease risk management system) for medical teams. The digital active health management of chronic diseases involved creating health streets, providing internet-assisted full-cycle active health services for residents, implementing internet-based community management for hypertension and diabetes, and performing real-time quantitative assessment and hierarchical management of residents' risks of cardio-cerebrovascular disease. After the 2-year intervention, management effectiveness was evaluated.
RESULTS: We constructed a digital health platform with interconnected health information and implemented a digital active health management model. After the intervention, the 2-way referral between community health care institutions and hospitals increased. Residents' health literacy rate increased from 30.6% (3062/10,000) in 2020 to 49.9% (4992/10,000) in 2022, with improvements in health knowledge, health behavior, and health skills. Moreover, the risk of cardio-cerebrovascular disease decreased after the intervention. The community hypertension and diabetes standardized management rates increased from 59.6% (2124/3566) and 55.8% (670/1200) in 2020 to 75.0% (3212/4285) and 69.4% (1686/2430) in 2022, respectively. The control rates of blood pressure in patients with hypertension and blood sugar in patients with diabetes increased from 51.7% (1081/2091) and 42.0% (373/888) in 2020 to 81.2% (1698/2091) and 73.0% (648/888) in 2022, respectively. The intervention improved patients' BMI, waist circumference, blood uric acid levels, and low-density lipoprotein cholesterol levels. The drug compliance rate of patients with hypertension and diabetes increased from 33.6% (703/2091) and 36.0% (320/888) in 2020 to 73.3% (1532/2091) and 75.8% (673/888) in 2022, respectively. The intervention greatly improved the diet behavior, exercise behavior, and drinking behavior of patients with hypertension and diabetes.
CONCLUSIONS: Our digital health platform can effectively achieve the interconnection and exchange of different health information. The digital active health management carried out with the assistance of this platform improved the effectiveness of community chronic disease management. Thus, the platform is worth promoting and applying in practice.