关键词: 高血压, 健康管理, 远程动态监测, 效果, 影响因素分析

Abstract: Objective　To explore the effect and associated factors of comprehensive community interventions for hypertension control based on remote ambulatory blood pressure monitoring（RABPM）.Methods　1 000 patients with hypertension were selected from 41 community health centers in Guangzhou between January 2015 and September 2016 by multi-stage random sampling.All of them signed a contract with the community general practitioner and enjoyed the one-to-one contractual services，and received the comprehensive community interventions for hypertension control delivered by health mangers，family doctors，and the patient's family members based on the blood pressure levels measured by a new type of RABMP.The intervention effects were evaluated by the status of hypertension control，health behaviors and BMI of patients at the end of 6-month，12-month and 18-month intervention.Multivariate Logistic regression analysis was carried out to determine the factors associated with hypertension control outcome.Results　A total of 954 cases who completed the trial were included for further analysis.The 18-month follow-up showed the following results：At the end of 6-month intervention，although the mean diastolic blood pressure（DBP） of the patients changed a little（P>0.05），the mean systolic blood pressure（SBP） decreased significantly（P<0.05） compared with baseline.Compared with at the end of 6-month intervention，both mean DBP and SBP levels of them were much lowered when they finished 12-month intervention（P<0.05）.When the 18-month intervention ended，the patients were found with both lower mean DBP and SBP levels compared with at the end of 12-month intervention（P<0.05），and were identified with lower rate of lack of exercise，lower mean BMI and longer mean duration of exercise（P<0.05） but similar prevalence of smoking and alcohol consumption（P>0.05） compared with baseline.The rate of hypertension control increased as the intervention went on（P<0.05）.Multivariate Logistic regression analysis revealed that age，concomitant illness，smoking and BMI were associated factors for hypertension control outcome（P<0.05）.Conclusion　 Comprehensive interventions based on RABPM could effectively improve the hypertension control outcome of community-dwelling hypertensive patients.Age，concomitant illness，smoking and BMI of the patients could influence the management effect.

Key words: Hypertension, Health managament, Remote ambulatory monitoring, Effect, Root cause analysis