目的评价武进区慢性病自我管理项目实施1年后的效果。方法将919名患有高血压和(或)糖尿病的患者按随机对照试验研究设计,随机分成干预组和对照组,比较两组在干预前后的自我效能、自我管理行为和卫生服务利用等方面的变化。结果 1年后干预组和对照组相比,平均收缩压多下降6.69 mm Hg,舒张压多下降1.89 mm Hg,空腹血糖多下降0.29mmol/L,体质指数多下降0.27kg/m2,差异均有统计学意义(P<0.05);自我效能评估,症状管理自我效能多增加0.29分,疾病共性管理自我效能多增加0.74分,差异均有统计学意义(P<0.05);自我管理行为,有氧锻炼多增加22.28min/周,认知症状管理多增加0.22分,与医生沟通情况多增加0.23分,差异均有统计学意义(P<0.05);卫生服务利用情况,干预组在近6个月内看门诊次数、急诊次数、住院次数和住院天数分别下降1.31次、0.03次、0.05次和0.48天,但差异未见统计学意义。结论开展慢性病自我管理项目能提高患者自我效能,改善自我管理行为,降低血压、血糖水平。 Objective To evaluate the effect of self-management of chronic diseases in Wujin District one year after implementation. Methods A total of 919 patients with hypertension and / or diabetes were randomized into intervention group and control group according to the randomized controlled trial design. The self-efficacy, self-management behavior and health service utilization of the two groups before and after intervention were compared Variety. Results Compared with the control group, the mean systolic blood pressure decreased by 6.69 mm Hg, the diastolic blood pressure decreased by 1.89 mm Hg, the fasting blood glucose decreased by 0.29 mmol / L, and the body mass index decreased by 0.27 kg / m 2 (P <0.05). Self-efficacy evaluation showed that self-efficacy of symptom management increased by 0.29 points and self-efficacy of common disease management increased by 0.74 points (P <0.05), self-management behavior and aerobic Exercise increased by 22.28min / week, cognitive symptoms management increased by 0.22 points, more communication with the doctor increased by 0.23 points, the differences were statistically significant (P <0.05); utilization of health services in the intervention group in the past 6 months The outpatient visits, emergency visits, hospitalizations and hospital stays decreased by 1.31, 0.03, 0.05 and 0.48 days, respectively, but the differences were not statistically significant. Conclusion Self-management of chronic diseases can improve patient self-efficacy, improve self-management behavior, lower blood pressure and blood glucose levels.