目的:了解徐州市农村地区慢性病患者健康管理服务开展情况。方法:采用多阶段分层随机抽样,抽取徐州市农村地区原发性高血压和2型糖尿病患者共400人,采用自行设计的问卷进行调查。结果:被调查人群就诊时测血压率68.6%,随着文化程度的升高、年龄的降低,测血压率呈上升趋势(P<0.05)。58.4%的患者被随访过,被随访者中,95.6%接受过用药和健康生活方式的指导,78.9%的患者在随访时免费测量血压或/和空腹血糖,43.7%的患者每年会接受一次免费体检,不同性别、年龄、职业和文化程度间随访情况以及体检情况差异均无统计学意义(P>0.05)。高血压患者的血压控制率为35.6%,糖尿病患者的血糖控制率为25.8%。结论:徐州市农村地区针对慢性病患者的健康管理服务初见成效,血压、血糖控制率较2008年的调查结果均有提高;但该项工作各地开展的很不均衡,应采取有针对性的措施,严格规范执行慢性病患者健康管理服务。 Objective: To understand the status of health management services for chronic patients in rural areas of Xuzhou City. Methods: A total of 400 patients with essential hypertension and type 2 diabetes mellitus were recruited from rural areas of Xuzhou using multi-stage stratified random sampling, and questionnaires were used to investigate. Results: The measured blood pressure was 68.6% at the time of treatment. With the increase of education level and age, the blood pressure rate showed an upward trend (P <0.05). Fifty-eight percent of the patients were followed up. Of those who were followed up, 95.6% had taken medication and a healthy lifestyle and 78.9% had free blood pressure and / or fasting blood glucose at follow-up, and 43.7% received one free per year Physical examination, gender, age, occupation and education were followed up as well as the physical examination showed no significant difference (P> 0.05). Blood pressure control rate was 35.6% in hypertensive patients and 25.8% in diabetic patients. Conclusion: The health management services for chronic patients in Xuzhou City have achieved initial success. The control rates of blood pressure and blood glucose are all higher than those of the survey in 2008. However, the work is not well balanced across the country, and targeted measures should be taken , Strictly regulate the implementation of health management services for patients with chronic diseases.