Objective To study the factors influencing the control of high blood pressure/glucose/lipids in community patients under the strategy of "Integrated Control and Prevention of Three Highs (high blood pressure/glucose/lipids) and Six Diseases (coronary heart disease, stroke, renal lesions, retinal lesions, peripheral neuropathy, and peripheral vascular lesions)" strategy, and to provide a reference for improving the chronic disease management model.

Methods The study included 34 500 elderly residents (≥60 years) with one or more elevated blood pressure/glucose/lipid levels who were under the management of "Integrated Control and Prevention of Three Highs and Six Diseases" strategy in Chengyang district, Qingdao city, Shandong province. Subjects′ demographics and 4 years (2019–2022) of consecutive blood pressure, glucose, and lipid monitoring data were collected from the Three Highs management information system. Generalized estimating equations were used to analyze the factors influencing the subjects′ blood pressure, blood glucose, and blood lipid control.

Results The overall blood pressure control rate showed a trend of first decreasing and then increasing, from 27.04% in 2019, decreasing to 26.07% in 2021, and then increasing to 27.88% in 2022. The overall blood glucose control rate also showed a trend of first decreasing and then increasing, from 60.07% in 2019, decreasing to 52.20% in 2021, and then increasing to 55.30% in 2022. The overall blood lipid control rate showed a trend of first decreasing and then increasing, from 55.20% in 2019, decreasing to 54.14% in 2020, and then increasing to 60.95% in 2022. Patients who were female, older, had local household registration, were illiterate or semi-literate, worked in agriculture, had multiple elevated blood pressure/glucose/lipid levels, and used more medications had lower blood pressure control rates. Patients who were male, aged 60–69 years, had local household registration, were illiterate or semi-literate, worked in agriculture, had multiple elevated blood pressure/glucose/lipid levels, and used more medications had a lower blood glucose control rate. Patients who were female, aged 60–69 years, had local household registration, were illiterate or semi-literate, had other occupations, had multiple elevated blood pressure/glucose/lipid levels, and used fewer medications had a lower blood lipid control rate.

Conclusions Under the "Integrated Control and Prevention of Three Highs and Six Diseases" strategy-based management, the blood pressure control rate and lipid control rate of elderly community residents with elevated indicators were effectively improved in Chengyang District, Qingdao City, and the blood glucose control rate was also improved. The chronic disease management model could be further promoted by strengthening lifestyle intervention and health education in key populations and continuously evaluating its effectiveness.