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.