Abstract: Background　The efficient and perfect chronic disease management model is of great importance. But the diversified chronic disease management models in China have not been thoroughly applied yet. Objective　To analyze the development situation of chronic disease management models currently at home and abroad，and summarize the existing bottlenecks and key issues，in order to propose the breakthroughs to the improvement of chronic disease management models in China. Methods　Chinese key words including "慢病/慢性病（chronic disease）" "慢病管理（chronic disease management）"
"慢病管理模式（chronic disease management model）" "现况（current situation）" "问题（problems）" "效果（effect）" and "评价（evaluation）"，and English key words including "chronic disease" "chronic disease management" "chronic disease management model" "current situation" "problem" "effect" and "evaluation" were used to search Google and Baidu search engine，CNKI，Wanfang，VIP，PubMed and Web of Science database from January 1，1990 to July 1，2019. The literature of nearly 30 years since 1990 had been sorted out and analyzed，and the defects and key problems of the current chronic disease management model had been sorted out according to the literature mention rate. Using Delphi method，the chronic disease management problems would be ranked according to the importance and severity after two rounds of interviews. The ranking based on the literature mention rate and the ranking based on expert interviews were combined to get a comprehensive ranking from low to high. Results　The top 10 core problems that hindered the application of the current chronic disease management model were the obstacles in the two-way referral work，the low enthusiasm of patients，the lack of community health service capacity，the lack of awareness of medical consortia，the lack of information technology level，the lack of long-term incentive mechanism，the lack of supporting policies，the lack of guidance of medical insurance policies，the loose structure of medical consortia，and the lack of government supervision. Conclusion　The key issues of the existing chronic disease management models were that the systematic and structural obstacles in two-way referral mechanism，passive participation of patients or families，and the uncompleted informatization construction. Through the two-way referral mechanism and the informatization construction，the high efficiency of the chronic disease management model is expected to fully mobilize the initiatives of various parties to achieve the positive participation as well as the effective collaboration of hospitals，communities and families.

Key words: Chronic disease management model, Current situation, Key issues, Breakthroughs

摘要： 背景　高效、完善的慢性病管理模式至关重要，但目前，慢性病管理模式虽多样化但在我国的应用仍旧不深入。目的　分析国内外慢性病管理模式的发展现状，总结现有的慢性病管理模式在我国应用的瓶颈和关键问题，提出我国慢性病管理模式改良的突破口。方法　以“慢病/慢性病”“慢病管理”“慢病管理模式”“现况”“问题”“效果”“评价”为中文检索词，以“chronic disease”“chronic disease management”“chronic disease management model”“current situation”“problem”“effect”“evaluation”为英文检索词，检索谷歌及百度搜索引擎、中国知网（CNKI）、万方数据知识服务平台、维普网、PubMed、Web of Science数据库，检索时间为1990-01-01至2019-07-01，对纳入文献进行整理分析，按照文献提及率梳理现有慢性病管理模式的缺陷及关键问题。运用德尔菲法，经过两轮访谈，根据重要性和严重程度将慢性病管理存在的问题进行排序。将按文献提及率进行的排名和专家访谈进行的排名数值相加按照从低到高得出综合排序。结果　阻碍当前慢性病管理模式应用的核心问题前10位分别为双向转诊工作存在障碍、患者积极性不高、社区卫生服务能力不足、对医联体的知晓度不够、信息技术水平不够、缺乏长期的激励机制、缺乏配套政策、医保政策缺乏引导、医联体结构松散、政府监管不到位。结论　现有的慢性病管理模式关键问题在于：机制性的双向转诊无法实现，患者/家庭方并未主动参与，信息化建设并不到位。高效的慢性病管理模式应通过双向转诊、信息化等机制，充分调动多方的积极性，实现各方之间互动参与和有效合作。

关键词: 慢性病管理模式, 现况, 关键问题, 突破口