背景 高血压是动脉粥样硬化性心血管疾病最重要的危险因素。合理的药物治疗、健康的生活方式、血压监测和随访管理是改善血压控制效果的有效措施。其中,随访管理对提高药物和非药物治疗依从性具有重要价值。但合适的随访频次以及随访频次是否与血压控制效果直接相关还缺少循证医学证据。目的 了解服药治疗的社区高血压患者门诊随访现状及其与血压控制的相关关系。方法 2019年1月至12月,在太阳宫社区卫生服务中心全科门诊连续纳入服药治疗的高血压患者。通过问卷调查和现场测量方法收集患者的相关信息。结果 共收集符合条件的高血压患者855例,女性534例(60.3%)。平均年龄68.2 ±8.5岁,65岁以上705例(79.7%)。采用两种降压药联合治疗的比例为65.8%(582/855)。门诊随访超过4次的比例为90.1% (767/855)。收缩压和舒张压水平随着门诊随访频次的增加而显著降低,和门诊随访1-3次/年的患者相比,门诊随访超过12次者收缩压降低8.3mmHg,舒张压降低5.3mmHg(P<0.001)。单因素logistic回归分析结果显示,门诊随访频次与血压控制效果相关。与年内门诊随访1-3次者相比,随访7-12次者比值比(OR)为1.68 [95%可信限(CI)：1.14-2.45],随访超过12次者OR=2.26(95%CI：1.39-3.68)；调整年龄、性别、高血压病程、缺血性心血管疾病以及糖尿病病史、超重和肥胖、现在吸烟、现在饮酒、体力活动的影响后,仍显示随访6次以上门诊随访与血压控制改善相关,且联系强度没有明显变化；进一步调整是否联合应用降压药以及参加健康教育次数后,和参考层相比,门诊随访7-12次与血压控制的改善无相关关系,随访12次以上与血压控制改善相关,OR=1.82(95%CI：1.10-3.03)。结论 90%以上采取降压治疗的社区高血压患者年内门诊随访4次以上；门诊随访6次以上者有益于血压控制,但降压药物联合应用对血压控制的效果更显著。

Background Hypertension is one of vital risk factors of atherosclerotic cardiovascular disease. Effective measures to control blood pressure contain reasonable medication, healthy lifestyle, blood pressure monitoring and follow-up management. Although follow-up management play an important role in enhancing treatment compliance,there is little evidence-based medicine between frequency of follow-up and blood pressure control effect. Objective To analyze the frequency of community clinic visiting and the relationship with blood pressure control among patients with treated hypertension. Method This was a cross-sectional study, patients with treated hypertension were enrolled consecutively from Tai yang gong community health service center from January through December 2019. All the subjects were asked to respond to an interviewer-led questionnaire, height, weight, and BP were measured at clinic. Results This study included 855 patients with treated hypertension (male, n=321, female, n=534), the mean age was (68.2±8.5) years, subjects aged ≥65 years was account for 79.7% (705/855). There were 582 subjects who took two or more anti-hypertensive combined drugs, 765 (90.1%) visited the community clinic four or more times per year. The levels of systolic blood pressure and diastolic blood pressure decreased significantly with an increasing number of community clinic visits. Compared with patients who visited a community clinic 1–3 times per year, systolic blood pressure decreased by 8.3mmHg and diastolic blood pressure decreased by 5.3mmHg in patients who visited a community clinic more than 12 times per year (all P<0.001). Single factor regression analysis showed that visiting a community clinic more than 6 times per year was associated with a higher odds ratio(OR)of blood pressure (BP) control than having the lowest frequency of clinic visits (1–3 times/year). The OR was1.68 [95% confidence intervals (CI)：1.14-2.45] for patients with clinic visits between 7 to 12 times, 2.26(95%CI：1.39-3.68)for patients with clinic visits between 7 to 12 times. The association between number of clinic visits and BP control remained significant after adjustment for sex, age, duration of hypertension, history of ischemic cardiovascular disease, diabetes, obesity/overweight, habits of smoking and drinking, and physical activity. While further adjustment for treatment with antihypertensive drugs and number of education sessions, only visiting a community clinic more than 12 times per year could an association be concluded with a higher OR (1.82, 95%CI:1.10-3.03)of BP control, no significant association was found between a community clinic visiting 7-12 times and BP control. Conclusion High proportion of patients with treated hypertension achieved a community clinic visits more than 4 times per year, and more than 6 times per year visits was associated with a higher OR of BP control than having the lowest frequency of clinic visits, but two or more anti-hypertensive combined treatment had stronger influence on BP control than that of 6-12 times per year visits.