Abstract:OBJECTIVE To explore the intervention effect of family doctor team management in rural areas on high-risk stroke patients. METHODS 280 patients with hypertension (high risk) with carotid plaques registered in the chronic disease registration management of Daqing Town Community Health Service Center in Pudong New Area,Shanghai were randomly divided into intervention group and control group. The management team adopted community comprehensive health education measures and follow-up under the management of the family doctor team. The parameters of the two groups were analyzed before and after the intervention. RESULTS Before and after the intervention, the management group decreased the proportion of smoking and drinking (P<0.05), and the normal proportion of blood pressure and the normal proportion of BMI increased (P<0.05). Compared with the control group before and after the intervention, the proportion of smokingand drinking also decreased (P>0.05). Compared with the control group, the proportion of smoking and drinking decreased more significantly in the management group (P<0.05). There was also a statistically significant difference between the normal ratio of blood pressure and the normal proportion of BMI (P<0.05). The proportion of patients who followed the health care plan, sought health promotion behavior, and recognized the disease was higher than thatbefore the intervention. At the same time, the proportion of physical exercise times ≥ 4 times/week increased from 9.29%to 54.29% (P<0.01). Compared with the control group, the management group had ahigher rate of compliance with the health care plan, seeking health promotion behaviors and physical exercise times ≥ 4 times/week (P<0.05). The levels of SBP, DBP, TC, TG, LDL-C and Hcy were decreased in the management group (P<0.01 or P<0.05), and HDL-C was higher than before the intervention (P<0.01). The scores of patients in the management group and the risk of 10-year stroke were significantly lower than those before the intervention (P<0.01). The scores of the intervention group and the 10-year stroke were lower in the management group than in the control group (P<0.01 or P<0.05). CONCLUSION The use of community-based comprehensive health education interventions in patients with hypertension and carotid plaque under the management of family doctors can better affect the main risk factors of stroke in patients, change the health-related behaviors of patients, and promote the improvement of relevant laboratory test indicators.