Abstract：Objective To evaluate the effect of community comprehensive management model intervention among patients with dyslipidemia, so as to provide the reference for optimizing community management strategies and improving the target achievement rate for blood lipids among this population. Methods From May to June 2023, a multi-stage stratified random sampling method was employed to select patients with dyslipidemia from primary healthcare institutions in Jiaxing City, Zhejiang Province. Eligible participants were randomly assigned to either a control group or an intervention group. The control group received routine management, while the intervention group was subjected to a community comprehensive management model in addition to the routine care. Both groups were followed up for 24 months. Data on demographic characteristics, lifestyle behaviors, physical examination indices, and blood biochemical indicators were collected at baseline and after the intervention through questionnaires, physical examinations, and laboratory tests. Changes in obesity rate, central obesity rate, target achievement rates for blood lipids, blood pressure, and blood glucose, as well as lifestyle modifications, were analyzed. Differences between the two groups before and after the intervention were assessed using generalized estimating equations (GEE). Results The control group consisted of 560 patients, including 303 females (54.11%) and 430 individuals aged ≥65 years (76.79%). The intervention group also included 560 patients, with 300 females (53.57%) and 431 individuals aged ≥65 years (76.96%). Before the intervention, no statistically significant differences were observed between the two groups in terms of gender, age, educational level, history of chronic diseases, and atherosclerotic cardiovascular disease risk stratification (all P>0.05). After 24 months of intervention, interaction effects between group and time were observed for obesity rate, central obesity rate, target achievement rate for blood lipids, target achievement rate for blood glucose, composite target achievement rate, physical activity rate, and medication adherence (all P<0.05). Specifically, the intervention group demonstrated lower rates of obesity and central obesity, and higher target achievement rate of blood lipids, target achievement rate of blood glucose, composite target achievement rate, physical activity rate, and medication adherence compared to the control group. Conclusion The community comprehensive management model contributed to improvements in multiple metabolic parameters (including body weight, waist circumference, blood lipids, and blood glucose) among patients with dyslipidemia, and was associated with increased physical activity rate and medication adherence.
高慧, 谢亮, 姚春阳, 王林红, 金鎏, 胡洁. 血脂异常患者社区综合管理模式的干预效果评价[J]. 预防医学, 2026, 38(1): 15-19.
GAO Hui, XIE Liang, YAO Chunyang, WANG Linhong, JIN Liu, HU Jie. Effect of community comprehensive management model intervention among patients with dyslipidemia. Preventive Medicine, 2026, 38(1): 15-19.
[1] 王增武,《中国心血管健康与疾病报告2024》编写组.《中国心血管健康与疾病报告2024》:心血管疾病及其危险因素流行状况[J].中国心血管病研究,2025,23(9):771-793. [2] RAJA V,AGUIAR C,ALSAYED N,et al.Non-hdl-cholesterol in dyslipidemia:review of the state-of-the-art literature and outlook[J/OL].Atherosclerosis,2023[2025-12-31].https://doi.org/10.1016/j.atherosclerosis.2023.117312. [3] XU S N,REN R C,LI W T,et al.The association between obesity indicators and metabolic risk factors in type-2 diabetic patients[J/OL].Heliyon,2023,9[2025-12-31].https://doi.org/10.1016/j.heliyon.2023.e20013. [4] 王增武,刘静,李建军,等.中国血脂管理指南(2023年)[J].中国循环杂志,2023,38(3):237-271. [5] 林晓玲,瞿楷校,李旭,等.医防融合视角下浙江省县域医共体慢性病一体化门诊服务开展现状评价及改进对策研究[J].中国全科医学,2025,28(13):1649-1654. [6] 诸骏仁,高润霖,赵水平,等.中国成人血脂异常防治指南(2016年修订版)[J].中国循环杂志,2016,31(10):937-953. [7] 尤莉莉,赵金红,陈新月,等.国家基本公共卫生服务项目实施十年的进展与成效[J].中国全科医学,2022,25(26):3209-3220. [8] 马程乘,孟萌,叶小琴,等.基于家庭医生签约服务的社区血脂异常强化管理的效果分析[J].中华健康管理学杂志,2019,13(6):490-497. [9] 《运动处方中国专家共识(2023)》专家组.运动处方中国专家共识(2023)[J].中国运动医学杂志,2023,42(1):3-13. [10] KONGKAR R,RUKSAKULPIWAT S,PHIANHASIN L,et al.The impact of interdisciplinary team-based care on the care and outcomes of chronically ill patients:a systematic review[J].J Multidiscip Healthc,2025,18:445-457. [11] 徐春霞,丁亚君,袁芸芸,等.北仑区多学科综合体重管理干预效果评价[J].预防医学,2025,37(11):1103-1107. [12] XU T,LIU C Y,TAO Y X,et al.Effects of a goal attainment theory-based intervention on physical activity,body composition,and motivation in emerging adults with physical inactivity:a randomized controlled trial[J/OL].Public Health,2025[2025-12-31].https://doi.org/10.1016/j.puhe.2024.12.007. [13] 严新凤,于传宁,曹思静,等.基本公共卫生服务下数字化赋能全-专协同社区慢性病路径化管理:实践探索与初步成效[J].中国全科医学,2025,28(31):3897-3903. [14] LIU M H,HUANG R H,XU L,et al.Cardiovascular effects of intensive lifestyle intervention in adults with overweight/obesity and type 2 diabetes according to body weight time in range[J/OL].EClinicalMedicine,2022[2025-12-31].https://doi.org/10.1016/j.eclinm.2022.101451. [15] 赵瑞,黄胜楠,肖暖.中等强度有氧运动预防高胆固醇血症患者动脉粥样硬化性心血管疾病效果评价[J].预防医学,2022,34(1):58-62. [16] LäHTEENVUO M,TIIHONEN J,SOLISMAA A,et al.Repurposing semaglutide and liraglutide for alcohol use disorder[J].JAMA Psychiatry,2025,82(1):94-98.
