Abstract: Background　Stroke interventions are very important for the reducing of stroke incidence in populations at high risk of stroke.Our research team implemented a delivery model of stroke interventions in populations at high risk of stroke in the rural community in a pilot way，namely，interventions co-delivered by general practitioners（GPs） and specialists，in order to improve the diagnostic and therapeutic level of community physicians and the life quality of rural residents.Objective　To explore the effectiveness of stroke interventions co-delivered by GPs and specialists in populations at high risk of stoke in the rural community.Methods　According to the inclusion criteria，459 residents at high risk of ischemic stroke were randomly selected from Lixin Village（intervention group，n=237） and Pengzhao Village（control group，n=222），Malu Town，Jiading District，Shanghai between March and April，2015.During June 2015 to June 2016，the intervention group received targeted interventions，tracking and follow-up services co-delivered by GPs and specialists based on their own conditions，while the control group received management delivered by GPs in accordance with the diagnostic and therapeutic guidelines.Physical examination and reexamination were conducted in a follow-up in July 2016.Pre- and post-intervention mean total cholesterol（TC），low-density lipoprotein cholesterol（LDL-C），systolic blood pressure（SBP），diastolic blood pressure（DBP） and carotid Doppler ultrasonography results were compared between the groups.For residents who were found with atherosclerotic plaque in two carotid Doppler ultrasonography examinations，pre- and post-intervention atherosclerotic plaque status was compared.Results　After intervention，mean TC，LDL-C，SBP and DBP levels of the intervention group were significantly lower than those of the control group（P<0.05）．The differences of carotid Doppler ultrasonography results between the two groups did not meet statistic significance（P>0.05）．58 in the intervention group and 72 in the control group were found with atherosclerotic plaque in pre- and post-intervention carotid Doppler ultrasonography examinations，but the differences in pre- and post-intervention atherosclerotic plaque overall status between the groups were not significant（P>0.05）．The rates of conversion of atherosclerotic plaque from unstable to stable in the intervention group（36.2%） and control group（20.8%） were not significantly different（χ2=3.792，P=0.052）．The rate of conversion of atherosclerotic plaque from stable to unstable in the intervention group （6.9%） was much lower than that of the control group（13.9%）（χ2=4.565，P=0.033）．Conclusion　Stroke interventions supervised and managed by GPs and specialists for in populations at high risk of stoke in the rural community，could effective control and reverse the high-risk factors of ischemic stroke，by which the incidence of stroke may be reduced.This delivery model is worth promoting in primary care.

Key words: Stroke；Hypoxia-ischemia, brain；High-risk factor；Plaque, atherosclerotic；Combined intervention of community physicians and specialist doctors；Community

摘要： 背景　脑卒中高危人群的有效干预对降低脑卒中的发病具有重要意义。本课题组尝试在农村社区开展全专联合干预脑卒中高危人群的服务模式，以提高社区全科医生的诊疗水平和农村居民的生活质量。目的　探究农村社区全专联合干预缺血性脑卒中高危人群的效果。方法　2015年3—4月于上海市嘉定区马陆镇立新村和彭赵村随机抽取符合纳入标准的459例缺血性脑卒中高危者为研究对象，其中立新村237例，彭赵村222例。将立新村人群作为干预组，彭赵村作为对照组。两组患者均于2015年6月—2016年6月进行干预。干预组由全科医生和专科医生共同根据每例脑卒中高危患者的具体情况，进行有针对性地干预、跟踪、随访。对照组由全科医生依据诊疗规范进行管理。2016年7月进行随访，内容包括体检和复查，并比较两组干预前后总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）、收缩压（SBP）、舒张压（DBP）、颈动脉彩超检查的变化情况，对2次颈动脉彩超检查均存在动脉粥样硬化斑块的患者进行颈动脉粥样硬化斑块情况的比较。结果　干预组患者干预后TC、LDL-C、SBP、DBP均低于对照组（P<0.05）。两组患者颈动脉彩超检查情况比较，差异无统计学意义（P>0.05）。干预组共58例患者2次颈动脉彩超检查均存在动脉粥样硬化斑块，对照组72例。两组2次颈动脉彩超检查均存在动脉粥样硬化斑块的患者动脉粥样硬化斑块情况的比较，差异无统计学意义（P>0.05）。干预组和对照组患者颈动脉粥样硬化斑块转为稳定的比例（分别为36.2%、20.8%）比较，差异无统计学意义（χ2=3.792，P=0.052）；干预组患者颈动脉粥样硬化斑块转为不稳定的比例（6.9%）低于对照组（13.9%）（χ2=4.565，P=0.033）。结论　基于农村社区卫生服务中心的全科医生和专科医生的联合监督管理，能有效控制甚至逆转缺血性脑卒中高危人群的高危因素，降低脑卒中发病率，值得在基层推广。

关键词: 卒中；缺血缺氧, 脑；高危因素；斑块, 动脉粥样硬化；全专联合；社区