Abstract: Background　At present，chronic diseases have become a major problem that seriously threatens resident's health in China and affects the country's economic and social development. As of 2015，the number of patients with chronic diseases in China reached 280 million，accounting for 70% of the total disease burden. For many complications and a long course of disease，effective follow-up work and methods can greatly delay the process of chronic diseases. Objective　To investigate the current status of chronic disease follow-up in China，and analyze the advantages and key problems of the existing follow-up methods，in order to explore the direction of improving success rate and quality of chronic disease follow-up. Methods　Systematically search the literature related to chronic disease follow-up in the databases of CNKI，WANFANG data knowledge service platform，CQVIP network，PubMed，Web of Science，and Scopus from January 1，2000 to July 31，2019，and comprehensively obtain the current situation and related problems of chronic disease follow-up in China. In August 2019，the non-structured interview + semi-structured interview method was adopted to conduct in-depth interviews with 12 doctors from different levels of medical institutions in a district of Shanghai on follow-up methods，its advantages and disadvantages，and bottlenecks. Based on literature meta-analysis and interview results，the current situation and key problems of chronic disease follow-up in China were summarized. Results　Face-to-face follow-up was the main method in community health service centers currently. The combination of face-to-face follow-up and telephone follow-up was commonly used in the secondary and tertiary general hospitals，but the efficiency was not high and the application of online intelligent follow-up was less. The key problems were poor initiative and compliance of the follow-up subjects，backward information technology，and insufficient allocation of follow-up resources. Conclusion　In the future，it is necessary to optimize the follow-up methods as well as stimulate patients' active health awareness with the help of intelligent technology to achieve effective management of chronic diseases.

Key words: Chronic diseases management, Follow-up studies, Current status, Problems, Meta analysis, Qualitative research

摘要： 背景　目前，慢性病已成为严重威胁我国居民健康、影响国家经济社会发展的重大问题。截至2015年，我国慢性病患者数达到2.8亿，导致的疾病负担已占到总疾病负担的70%。慢性病并发症多、病程长，有效的随访工作和随访方式可大大延缓慢性病进程。目的　调查我国当前慢性病随访情况，剖析已有随访方式的优缺点及关键问题，探索提高慢性病随访成功率、改善随访质量的方向。方法　系统检索2000-01-01至2019-07-31中国知网（CNKI）、万方数据知识服务平台、维普网、PubMed、Web of Science、Scopus数据库中与慢性病随访有关的文献，全面获得我国慢性病随访现状及相关问题；于2019年8月，采用非结构式访谈和半结构式访谈法对12例来自上海市某区不同级别医疗机构的医生就随访方式、优缺点、瓶颈等开展深入访谈。结合文献荟萃分析和访谈结果，归纳出我国慢性病随访开展现况及关键问题。结果　目前，面对面随访为社区卫生服务中心的主要随访方式，二、三级综合性医院普遍使用面对面随访与电话随访相结合的方式，但效率不高，网络智能随访应用较少。关键问题在于：随访工作主体主动性与依从性较差、信息技术水平落后及随访资源配置不足等。结论　未来需优化随访模式，借助于智慧化形式，激发患者主动健康意识，实现有效的慢性病管理。

关键词: 慢性病管理, 随访研究, 现状, 问题, 文献荟萃, 定性研究