本研究依托北京大学首钢医院古城社区卫生服务中心的慢性病管理系统，对慢性病管理现状进行分析，以期为其他基层卫生服务机构及慢性病研究提供参考。

本研究通过分层随机抽样及当面随访相结合的方式调查目前北京市古城社区对可引起动脉粥样硬化的慢性病（高血压、糖尿病、高脂血症和睡眠障碍）的控制现状。

研究发现慢性病中，高血压患病率最高（88.22%），并且用药较为合理，血压控制较为满意（53.61%）。高脂血症患病率为26.64%，用药较为规范合理，血脂控制满意（78.99%）。糖尿病患病率（39.19%）仅次于高血压，糖尿病用药相对较简单，随访中发现大部分糖尿病患者血糖控制欠佳（70.94%）。同时，社区慢病患者较为依赖中药制剂辅助治疗，这个问题需引起注意。此外，慢性病患者易合并睡眠障碍，常需口服镇静催眠药（36.49%）辅助睡眠，忽略了睡眠障碍实质是非躯体障碍，心理干预也许效果更好。

针对以上调查中发现的成就及暴露出的问题，采取相应措施，扬长补短，发挥首钢医院三级诊疗医联体的独特优势，助力“健康中国2030”。

Based on the chronic disease management system of Gucheng Community Healthy Community Health Service Center of Peking University Shougang Hospital, this study analyzed the current situation of chronic disease management, in order to provide reference for other primory healthy service situations and chronic disease research.

This study investigated the control status of chronic diseases (hypertension, diabetes, hyperlipidemia, and sleep disorders) that can cause atherosclerosis in Gucheng Community Healthy Service Center of Beijing by means of stratified random sampling and face-to-face follow-up.

Hypertension had the highest prevalence rate of chronic diseases (88.22%); the medication was reasonable and blood pressure control was satisfactory (53.61%). The prevalence rate of hyperlipidemia was 26.64%, the medication was standardized and reasonable, and lipid control was satisfactory (78.99%). The prevalence of diabetes (39.19%) was second only to hypertension; diabetes medication was relatively simple, and it was found in the follow-up that most patients with diabetes had poor blood glucose control (70.94%). Patients with chronic disease in the community were more dependent on TCM adjuvant therapy, to which attention should be paid. Patients with chronic diseases were easily complicated with sleep disorders and often need oral sedative hypnotics (36.49%) to assist sleep, which ignored the fact that sleep disorders are non-physical disorders in nature and psychological intervention may have better effects.

In view of the findings in the above investigation and the problems exposed, corresponding measures should be taken to make good use of our strengths and complement our weaknesses, give full play to the unique advantages of Shougang Hospital three-level medical association, and make contribution to the Healthy China 2030 initiative.