Objective:

To develop, implement, and evaluate a community-based, patient-centered integrated care model for atrial fibrillation (AF) characterized by generalist-specialist collaboration and cardio-cerebrovascular co-management, and to examine whether its effectiveness varies across key patient subgroups.

Approach:

• Study Design: A prospective, single-blind, randomized controlled trial was conducted with 160 patients with AF enrolled from community health centers.
• Intervention: The intervention group received comprehensive management based on a collaborative framework between general practitioners and specialists, while the control group received routine chronic disease management.
• Outcome Measures: Outcomes included attainment rates for BMI, blood pressure, blood glucose control, NT-proBNP levels, LVEF, medication use, and primary composite endpoint (heart failure or stroke).
• Subgroup Analysis: Subgroup analyses were conducted based on age, sex, and CHA2DS2-VASc score.

Key Findings:

• The intervention group had significantly higher attainment rates for BMI, blood pressure, and blood glucose control compared to the control group.
• LVEF showed significant improvement in the intervention group, while NT-proBNP levels did not differ significantly between groups.
• Standardized usage rates for anticoagulant and heart rate control medications were higher in the intervention group.
• The incidence of the composite outcome (heart failure or stroke) was significantly lower in the intervention group.
• No significant interactions were found in subgroup analyses for age, sex, or CHA2DS2-VASc score.

Interpretation:

The generalist-specialist collaborative integrated care model effectively improves risk factor control, cardiac function, and treatment standardization, and reduces major adverse cardiovascular events in community-dwelling AF patients.

Limitations:

• The study was limited to a single community health service center.
• The follow-up period was only 12 months.

Conclusion:

The benefits of the collaborative care model are consistent across age, sex, and comorbidity burden subgroups, supporting its broad applicability in primary care settings.