RESUMO
OBJECTIVE:To provide reference for comprehensive intervention and management of chronic disease in China.METHODS:The global chronic disease trends and disease burden were summarized;theoretical framework,practice and experience of international chronic disease management were summarized and analyzed as well as enlightenment on domestic chronic disease management.RESULTS&CONCLUSIONS:Worldwide prepresentative chronic disease theory model mainly involved USA chronic disease nursing model and WHO innovation care for chronic conditions.Main experience of international chronic disease management is that managing based on community,confirming preferential intervened disease types,adopting standardized clinical diagnosis and treatment pathway,designing rational transfer treatment system,providing patient self-management support.At pres ent,chronic disease management have been improved in China,but is still poor in community management.It is necessary to strengthen community medical staff training about chronic disease prevention and treatment and health education for social group.