慢性非传染性疾病(慢性病)的发病率迅速增加,已成为严重危害我国人民健康的重要公共卫生问题[1]。但目前社区慢性病患者管理存在很多问题,诸如居民自我保健意识薄弱,信息化管理信息系统尚不完善等[2-3]。有人对寻求既大大提高慢性病的预防和治疗又节省人力、物力的行之有效的管理模式进行了探索[4],也有人对社区慢性病患 The rapid increase in the incidence of chronic non-communicable diseases (chronic diseases) has become an important public health problem that has seriously endangered the health of our people [1]. However, there are many problems in the management of patients with chronic diseases in the community at present, such as the weak self-care awareness of residents and the imperfect information management information system [2-3]. Some people have explored effective management methods that seek to both prevent and treat chronic diseases and save manpower and resources [4], and also some people who have chronic diseases in the community