Abstract: Background Starting from chronic diseases such as hypertension in 2014，Xiamen City has innovatively launched the "Three Teachers Joint Management" family doctor contract service model，providing patients with continuous services of "prevention，screening，treatment，management，education，and health"，improving service quality，promoting doctor-patient harmony，and enhancing patients' sense of gain. However，there is currently a lack of research on the application effect of this model. Objective This article takes elderly hypertensive patients as the starting point to understand the health management effect of the "three teacher co management" family doctor contract service in Xiamen on elderly hypertensive patients，and analyzes the factors that affect patient blood pressure control，providing reference for continuously improving the health management effect of this service model. Methods Using a retrospective cohort study method，in March 2024，hypertensive patients aged 65 and above who participated in family doctor contract services for the first time in 2021 and received family doctor contract services for two consecutive years in six administrative districts under Xiamen City were selected as the contract group（n=15 154），and hypertensive patients aged 65 and above who had never participated in family doctor contract services were selected as the non contract group（n=8 838）. Collect general demographic information，lifestyle information，illness and medication status of patients through the Xiamen Basic Public Health Cloud Platform，match patients' participation in family doctor contract services through the "Xiamen eHealth" platform，and collect patient physical examination results through the Xiamen Elderly Health Examination Data Platform. Compare and analyze the blood pressure control，physical examination results，lifestyle，and medication compliance of patients in the contracted and unsigned groups in 2021（baseline） and 2023，and use multiple logistic regression analysis to investigate the impact of family doctor contracted services on patient blood pressure control. Results The blood pressure control rate of patients in the contracted group in 2023 was higher than that in 2021［60.10%（9 108/15 154） vs 76.78%（11 635/15 154），P<0.05］；the blood pressure control rate of patients in the unsigned group in 2023 was not significantly different from that in 2021［62.24%（5 501/8 838） vs 68.61%（6 064/8 838），P>0.05］. Compared with 2021, the average decrease in left diastolic blood pressure and right systolic blood pressure of contracted patients was significantly different from that of unsigned patients（both P<0.05）. The mean BMI and waist to height ratio of the contracted group patients decreased compared to 2021（P<0.05）. The proportion of abnormal BMI，excessive waist to height ratio，fasting blood glucose measurement ≥ 7.0 mmol/L，and abnormal electrocardiogram also decreased（P<0.05）. The exercise performance and medication adherence were significantly improved（P<0.05）. The results of logistic regression analysis showed that signing up was more beneficial for blood pressure control in elderly hypertensive patients than not signing up（OR=1.625，95%CI=1.536-1.719，P<0.05）. Conclusion The family doctor contract service in Xiamen has played a positive role in blood pressure control for elderly hypertensive patients. With the intervention of the family doctor team，patients can carry out more refined and personalized full process health management，improve their lifestyle，increase compliance，and achieve better hypertension control rates.

Key words: Contracted family doctor services, Hypertension, Health management, Community health services, Blood pressure control, Xiamen

摘要： 背景 厦门市自2014年开始以高血压等慢性病为切入口创新性地开展了“三师共管”家庭医生签约服务模式，为患者提供“防、筛、治、管、教、康”一体的连续服务，提升了服务质量，促进了医患和谐，提升了患者获得感，但目前关于该模式应用效果的研究较为缺乏。目的 了解“三师共管”家庭医生签约服务对老年高血压患者的健康管理效果，并分析影响患者血压控制的因素，为持续提升该服务模式的健康管理效果提供参考。方法 采用回顾性队列研究方法，于2024年3月，选取厦门市下辖6个行政区2021年首次参与家庭医生签约服务且连续2年接受家庭医生签约服务的≥65岁高血压患者为签约组（n=15154），选取从未参与家庭医生签约服务的≥65岁高血压患者为未签约组（n=8838）。通过厦门市基本公共卫生云平台收集患者的一般人口学信息、生活方式信息、患病和用药情况等，通过“厦门i健康”平台匹配患者参与家庭医生签约服务情况，通过厦门市老年人健康体检数据平台收集患者体检结果。对比分析2021年（基线）和2023年签约组与未签约组患者的血压控制情况、体检结果、生活方式及用药依从性，采用多因素Logistic回归分析家庭医生签约服务对患者血压控制的影响。结果 签约组患者的血压控制率从2021年的60.10%（9108/15154）提高到2023年的76.78%（11635/15154），两年份间比较，差异有统计学意义（P=0.010）；未签约组患者的血压控制率从2021年的62.24%（5501/8838）提高到2023年的68.61%（6064/8838），两年份间比较，差异无统计学意义（P=0.298）。签约组患者2023年左侧舒张压、右侧收缩压较2021年的下降幅度大于未签约组（P<0.05）。签约组患者2023年的BMI分布及中心性肥胖、空腹血糖偏高、心电图检查异常发生率较2021年改善（P<0.05），运动情况和服药依从性较2021年亦有改善（P<0.05）。多因素Logistic回归分析结果显示，签约家庭医生患者的血糖控制达标率是未签约者的1.625倍（95%CI=1.536~1.719）。结论 “三师共管”家庭医生签约服务对老年高血压患者的血压控制起积极作用，患者在家庭医生团队的干预下，开展更精细化、个体化的全程健康管理，生活方式得到改善，服务依从性更高，高血压控制率更好。

关键词: 家庭医生签约服务, 高血压, 健康管理, 社区卫生服务, 血压控制, 厦门