Longitudinal Changes in Cardiometabolic Risk Factor Control During Community-Based Integrated Management of Hypertension, Diabetes, and Dyslipidemia: A Retrospective Cohort Study

Background Hypertension, diabetes, and dyslipidemia often coexist and increase cardiovascular risk. Evidence regarding longitudinal changes in multiple cardiometabolic risk factors under integrated primary care management remains limited. This study evaluated cardiometabolic risk factor control during routine community-based management. Methods This retrospective longitudinal cohort study included adults enrolled in an integrated management program for hypertension, diabetes, and dyslipidemia at a community health center in Foshan, China. Routinely collected electronic health records from January 2024 to June 2026 were analyzed. Longitudinal changes in blood pressure, fasting blood glucose (FBG), lipid profiles, and comprehensive cardiometabolic control were assessed using linear mixed-effects models. Results Among 19,827 participants, 7,286 had repeated blood pressure measurements. Blood pressure remained stable over 24 months (both P < 0.001). Among participants with available repeated FBG measurements (N = 4,498), glycemic control improved from 72.1% at baseline to approximately 80% during follow-up. Among participants with available LDL-C measurements (N = 1,941), LDL-C target attainment increased from 30.6% to 57.0% at 12 months (P < 0.001). However, comprehensive control of blood pressure, FBG, and LDL-C remained suboptimal, increasing from 18.6% to approximately 29%. Conclusions Integrated community-based management was associated with sustained blood pressure control and improved glycemic and lipid indicators. However, achieving comprehensive cardiometabolic control remains challenging, highlighting the need for optimized risk-based management strategies in primary care.