Exploring a general practice management model for elderly patients with atrial fibrillation based on the ICCC framework

XU Yankai; SHI Shilin; LYU Fuqiang; LIU Kejian

doi:10.16766/j.cnki.issn.1674-4152.004028

Volume 23 Issue 6

Jun. 2025

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Article Navigation > Chinese Journal of General Practice > 2025 > 23(6): 903-906

XU Yankai, SHI Shilin, LYU Fuqiang, LIU Kejian. Exploring a general practice management model for elderly patients with atrial fibrillation based on the ICCC framework[J]. Chinese Journal of General Practice, 2025, 23(6): 903-906. doi: 10.16766/j.cnki.issn.1674-4152.004028

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XU Yankai, SHI Shilin, LYU Fuqiang, LIU Kejian. Exploring a general practice management model for elderly patients with atrial fibrillation based on the ICCC framework[J]. Chinese Journal of General Practice, 2025, 23(6): 903-906. doi: 10.16766/j.cnki.issn.1674-4152.004028

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Exploring a general practice management model for elderly patients with atrial fibrillation based on the ICCC framework

doi: 10.16766/j.cnki.issn.1674-4152.004028

XU Yankai^{1, 2}
, SHI Shilin^{1, 3}
, LYU Fuqiang^{1, 2}
, LIU Kejian^{3
,
,}

1.
School of Medicine, Shihezi University, Shihezi, Xinjiang 832000, China

Funds:

2023AB018-12

兵卫函〔2024〕15号

Received Date: 2025-01-23
Available Online: 2025-09-04

Abstract

Abstract

As a chronic disease with high morbidity and disability rates, atrial fibrillation (AF) presents a significant challenge to the primary healthcare system in elderly populations. The Innovative Care for Chronic Conditions (ICCC) framework proposed by the World Health Organization provides a theoretical basis for developing a general practice management model in elderly patients with AF, addressing macro, meso, and micro levels. The global incidence of atrial fibrillation continues to rise, and in China, the disease burden and stroke risk among elderly patients with atrial fibrillation are particular pressing concerns. General practitioners, as the core of community-level health management, are responsible for screening, treatment, and patient management. However, the current management model still faces challenges such as insufficient screening efficiency, unequal resource distribution, and poor health awareness of patients. Based on ICCC framework, this paper discusses the general practice management model for elderly patients with atrial fibrillation across three levels. Firstly, it is necessary to strengthen policy support and guidance at the macro level, encouraging all regions to carry out individualized, practice-wide management approaches supported by the allocation of health resources. Secondly, at the meso level, a multidisciplinary team led by general practitioners should be built to improve the bidirectional referral mechanism. Integrating artificial intelligence technology can further improve the accuracy of treatment and the effective use of resources. Finally, at the micro level, health education for elderly patients with atrial fibrillation and their families should be prioritized, and with a focus on empowering patients through family support, lifestyle intervention, and self-monitoring. In the future, improvements in the management of screening, primary care capacity, and the intervention of lifestyle are necessary to provide more efficient and comprehensive general practice management services for elderly patients with atrial fibrillation.
- Atrial fibrillation,
- Innovative Care for Chronic Conditions framework,
- Elderly,
- General management

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References(43)

References

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Exploring a general practice management model for elderly patients with atrial fibrillation based on the ICCC framework

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Exploring a general practice management model for elderly patients with atrial fibrillation based on the ICCC framework

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