高血压，糖尿病，冠心病和缺血性脑血管病等慢性病的有效管理，是社区全科医生的重要工作内容，也是一个比较困难的课题。
It is an important yet a difficult task for family physicians to efficiently manage chronic diseases like hypertension, diabetes, coronary heart diseases and ischemic cerebrovascular diseases.
探索用社区导向基层医疗（COPC）模式，对社区高血压病、糖尿病患者进行系统管理的效果。
To explore the effect of systematic management of hypertension and diabetes with community oriented primary care (COPC) model.
目的：探讨高血压的社区综合性管理与控制。
Objective: To investigate the comprehension management and control of hypertension in the communities.
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