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

摘要： 目的　探讨远程动态血压监测下综合干预在社区高血压管理中的应用效果及影响因素。方法　于2015年1月—2016年9月采用多阶段随机抽样法，在广州市抽取41家社区服务中心的1 000例高血压患者。患者与社区全科医生签约，享受“一对一”的家庭医生签约服务；利用具有长传功能的新型高血压远程动态监测管理系统，由健康管理员、家庭医生、患者家属对患者进行综合干预。比较患者干预期间的血压控制情况、健康行为和BMI，采用多因素Logistic回归分析探讨患者血压控制效果的影响因素。结果　共954例高血压患者完成了18个月的随访。干预6个月后患者收缩压低于干预前，差异有统计学意义（P<0.05）；但舒张压与干预前比较，差异无统计学意义（P>0.05）。干预12个月后患者收缩压、舒张压均低于干预6个月后，差异有统计学意义（P<0.05）；干预18个月后患者收缩压、舒张压均低于干预12个月后，差异有统计学意义（P<0.05）。随着干预时间的延长，患者的血压控制率逐渐升高（P<0.05）。干预18个月后患者缺乏运动的比例和BMI低于干预前，每次锻炼时间长于干预前，差异有统计学意义（P<0.05）；但患者吸烟、饮酒的比例与干预前比较，差异无统计学意义（P>0.05）。多因素Logistic回归分析结果显示，年龄、合并症情况、吸烟情况、BMI是患者血压是否得到有效控制的影响因素（P<0.05）。结论　远程动态血压监测下综合干预能够有效提高社区高血压患者的血压控制效果，年龄、合并症情况、吸烟情况、BMI是该模式下患者血压控制效果的影响因素。

关键词: 高血压, 健康管理, 远程动态监测, 效果, 影响因素分析