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目的探讨社区脑卒中高危人群实施个性化随访管理的效果及临床意义。方法选取北京市海淀区东升镇社区卫生服务中心所辖社区居民中200例具有三项及三项以上脑卒中高危因素人群随机分为研究组和对照组各100例。对照组采用社区常规随访管理，研究组采用个性化随访管理，评价随访管理3年后的效果。结果研究组脑卒中危险因素监测指标低于对照组，差异有统计学意义（<0.05）。高危人群的控制率、居民及家属满意度均有明显的提高差异有统计学意义(<0.05)。结论采用社区脑卒中高危人群个性化随访管理，有效控制高危因素，降低脑卒中的发生，对脑卒中防治意义重大。“,”Objective To investigate the effect and clinical significance of individualized follow-up management for the high risk population in community stroke patients. Methods Selected community health service centers in Beijing, Haidian District, Dongsheng Town under the jurisdiction of the community residents in 200 with three or more than three brain stroke risk factors of the crowd were randomly divided into the study group and control group with 100 cases in each. In the control group, the patients were followed up with routine management, and the study group was followed up for 3 years. Results The risk factors of stroke in the study group were lower than those in the control group, the difference was statistically significant ( <0.05). The control rate, residents and family satisfaction of high risk population were significantly improved, and the difference was statistically significant ( <0.05). Conclusion The high risk factors of stroke prevention and control were significant in the treatment of high risk factors and reducing the incidence of stroke.