Chronic Disease Co-Care Pilot Scheme shows high detection rate, improves cardiometabolic outcomes

Approximately 40 percent of individuals who received screening through the Chronic Disease Co-Care (CDCC) Pilot Scheme were found to have diabetes mellitus (DM), hypertension (HTN) or prediabetes. Their cardiometabolic outcomes improved following multidisciplinary management.

Launched in November 2023, the CDCC Pilot Scheme is a community-based public-private partnership primary healthcare programme that provides subsidized screening of chronic conditions to eligible residents of Hong Kong. Participants found to have DM, HTN or prediabetes are offered timely multidisciplinary management. As of January 2026, scheme enrolment had surpassed 200,000 – 10 months ahead of the government’s original target schedule.

Improved outcomes at 1 year

Researchers from the Department of Family Medicine and Primary Care, University of Hong Kong (HKU) were commissioned to evaluate clinical outcomes of the scheme. Data from 26,990 participants who had completed screening by 30 June 2024 were analyzed.

Among participants newly diagnosed with DM, HTN or prediabetes through the scheme, 5,950 received multidisciplinary management and completed 1-year follow-up. Results showed improvements in their cardiometabolic parameters at 1 year:

·      Participants with DM: Mean HbA_1c decreased from 7.76 to 6.70 percent, systolic blood pressure (SBP) decreased by 7.01 mm Hg, and LDL-cholesterol (LDL-C) decreased by 0.76 mmol/L;

·      Participants with HTN: Mean SBP decreased by 14.87 mm Hg, and LDL-C decreased by 0.56 mmol/L;

·      Participants with prediabetes: Mean BMI decreased by 0.52 kg/m², and LDL-C decreased by 0.41 mmol/L.

A matched case-control analysis evaluated treatment target achievement using data from 1,597 participants from the 1-year follow-up cohort and 412 non-participant controls who did not receive management for the relevant diagnoses in the public or private sector during the same period. Compared with controls:

·      HbA_1c <7 percent was 2.8 times more likely to be achieved in scheme participants with DM at 1 year;

·      SBP <140 mm Hg and risk-based LDL-C targets were 0.5 and 1.1 times more likely to be achieved in scheme participants with HTN;

·      BMI <25 kg/m² was 2.9 times more likely to be achieved in scheme participants with prediabetes.

“International and local studies demonstrate significant benefits of comprehensive screening and multidisciplinary management, showing reductions in risk of death as well as complications of type 2 diabetes [T2D] and HTN,” said Professor William Wong of the Department of Family Medicine and Primary Care, HKU. [J Clin Hypertens (Greenwich) 2025;27:e70053; Diabetes Care 2022;45:2871-2882; Eur J Prev Cardiol 2026;33:1151-1161]

“The CDCC Pilot Scheme is projected to reduce 10-year risks of peripheral vascular disease by 10 percent, stroke and heart failure by 9 percent, T2D by 8 percent, and chronic kidney disease by 3 percent,” he continued.

High satisfaction & self-enablement

Among 614 scheme participants recruited through District Health Centres (DHCs) and DHC Expresses across Hong Kong, >96 percent considered DHC services (including dedicated nurse clinics and health education programmes) necessary and helpful, effectively complementing consultations provided by the scheme’s family doctors.

“More than 90 percent of respondents reported an increased ability to understand, manage, and cope with their health conditions,” said principal investigator Dr Eric Wan of the Department of Family Medicine and Primary Care, HKU. “Participants gave the scheme high ratings, with scores of 80/100 for overall impression and 78/100 for consultations with paired family doctors.”