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Article(id=1322931448969310360, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322931411006665649, articleNumber=null, orderNo=null, doi=10.12102/j.issn.1009-6493.2026.13.001, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1766678400000, receivedDateStr=2025-12-26, revisedDate=1779033600000, revisedDateStr=2026-05-18, acceptedDate=null, acceptedDateStr=null, onlineDate=1793341036311, onlineDateStr=2026-10-30, pubDate=1783612800000, pubDateStr=2026-07-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793341036311, onlineIssueDateStr=2026-10-30, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793341036311, creator=13701087609, updateTime=1793341036311, updator=13701087609, issue=Issue{id=1322931411006665649, tenantId=1146029695717560320, journalId=1220038315760373764, year='2026', volume='40', issue='13', pageStart='2193', pageEnd='2384', issueExtLink='null', onlineDate='null', pubDate='1783612800000', pubDateStr='2026-07-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793341027261, creator='13701087609', updateTime=1793343114456, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322940165425082661, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322931411006665649, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322940165425082662, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322931411006665649, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=2193, endPage=2203, ext={EN=ArticleExt(id=1322931449220968602, articleId=1322931448969310360, tenantId=1146029695717560320, journalId=1220038315760373764, language=EN, title=Standards, guidelines, and expert consensus on appropriate technologies for chronic disease care: a scoping review, columnId=1322931449141276825, journalTitle=Chinese Nursing Research, columnName=Chronic Disease Topic, runingTitle=null, highlight=null, articleAbstract=
Objective

To conduct a scoping review of relevant standards,guidelines,and expert consensus on appropriate technologies for chronic disease care,so as to provide references for healthcare professionals in the health care practice of patients with chronic diseases.

Methods

Following the methodological framework of scoping reviews,15 Chinese and English databases including CNKI,Wanfang Data,VIP,SinoMed,PubMed,Web of Science,EMbase,CINAHL,Cochrane Library,Guidelines International Network(GIN),National Institute for Health and Care Excellence(NICE),Scottish Intercollegiate Guidelines Network(SIGN),World Health Organization(WHO) website,UpToDate,and Medlive were systematically searched,supplemented by a search of national and regional standards information service platforms.The search period spanned from the establishment of each database to September 30,2025. The included literature was systematically screened,organized,and analyzed.

Results

A total of 60 articles were included,comprising 28 guidelines,24 expert consensuses,1 best evidence summary,and 7 standards.These focused on common chronic diseases such as diabetes,hypertension,stroke,and chronic obstructive pulmonary disease.Three main categories of appropriate technologies for chronic disease care were identified:digital health technologies(including network services,remote interaction,mobile applications,and intelligent sensing),appropriate traditional Chinese medicine technologies(including external treatments and therapeutic exercises),and health management technologies(including behavioral and lifestyle interventions,psychological and social support,and holistic care).

Conclusions

Current appropriate technologies for chronic disease care have initially formed a diversified technological system covering digital health,traditional medicine,and health management.Future efforts should focus on enhancing the integrated application and localized practice of various technologies,and establishing standardized evaluation systems and promotion mechanisms to systematically improve the quality of chronic disease care.

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目的

对慢性病照护适宜技术的相关标准、指南及专家共识进行范围审查，为医务工作者在慢性病病人健康照护实践中提供参考。

方法

依据范围审查方法学框架，系统检索中国知网、万方数据知识服务平台、维普中文科技期刊、中国生物医学文献数据库、PubMed、Web of Science、EMbase、CINAHL、Cochrane Library、全球指南实施联盟（GIN）、英国国家卫生与临床优化研究所（NICE）、苏格兰校际指南网络（SIGN）、世界卫生组织（WHO）网站、UpToDate、医脉通15个中英文数据库，并补充检索国家及地区标准信息服务平台。检索时限为建库至2025年9月30日，对纳入文献进行系统筛选、整理与分析。

结果

共纳入60篇文献，包括指南 28 篇、专家共识24篇、最佳证据总结1篇、标准7篇，聚焦糖尿病、高血压、脑卒中、慢性阻塞性肺病等常见慢性病；归纳出三大类慢性病照护适宜技术，即数字健康技术（含网络服务、远程交互、移动应用、智能感知）、中医适宜技术（含中医外治、中医运动）、健康管理技术（含行为与生活方式干预、心理与社会支持、整体照护）。

结论

当前慢性病照护适宜技术已初步形成涵盖数字健康、传统医学和健康管理等多元化技术体系。未来应加强各类技术的整合应用与本土化实践，构建标准化的评价体系与推广机制，从而系统化提升慢性病照护质量。

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尹梅华，主管护师，博士研究生

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孙宏玉，E-mail：
SUN Hongyu, E-mail:
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Basic characteristics of included literature

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作者/年份/标准编号国家文献类型疾病病种适宜技术类型证据来源应用场景技术类别质量评价
樊长征等[8]2020中国指南慢性阻塞性肺疾病单病中医文献院内B中等质量
李建生[9]2020中国指南慢性阻塞性肺疾病单病中医康复证据为基础无限制B中等质量
中华医学会糖尿病学分会[10]2021中国指南2型糖尿病单病预防策略、健康教育与管理未注明无限制C中等质量
郭立新等[11]2024中国指南2型糖尿病单病运动治疗证据为基础无限制C高质量
顾东风等[12]2020中国指南心血管代谢疾病共病生活方式证据为基础无限制C中等质量
中华预防医学会糖尿病预防与控制专业委员会[13]2025中国指南糖尿病单病行为与生活方式干预证据为基础无限制C中等质量
郑丽等[14]2024中国指南脑卒中后偏瘫单病中医适宜技术证据为基础无限制B中等质量
Cohen等[15]2016美国指南头颈癌单种行为与生活方式干预NCCN、ASCO无限制C中等质量
Howell等[16]2011加拿大指南癌症单种行为与生活方式干预证据为基础无限制C高质量
Humphris[17]2016英国指南头颈部癌症单种行为与生活方式干预证据为基础无限制C中等质量
中华医学会心血管病分会等[18]2017中国指南心血管代谢性共病共病健康教育、行为与生活方式干预证据为基础院外C中等质量
吴兆苏等[19]2014中国指南高血压单种行为与生活方式干预证据为基础无限制C中等质量
王文[20]2015中国指南高血压单种健康教育、生活方式干预证据为基础无限制C中等质量
世界中医药学会联合会肺康复专业委员会[21]2020中国指南慢性阻塞性肺疾病单病中医康复技术循证医学无限制B中等质量
中医康复医学会中西医结合专业委员会中医康复学组[22]2021中国指南缺血性脑卒中单病中医康复技术循证医学无限制B中等质量
Rippe[23]2025美国指南2型糖尿病共病生活方式干预循证医学无限制C中等质量
Jain等[24]2022加拿大指南心血管疾病单病健康行为干预循证医学无限制C中等质量
SIGN[25]2017英国指南心脏疾病共病综合康复干预循证医学、专家意见无限制A,C中等质量
中国老年学和老年医学学会[26]2023中国指南2型糖尿病单病生活方式干预、中医适宜技术循证医学无限制B,C中等质量
中国老年学和老年医学学会[27]2022中国指南缺血性脑卒中单病生活方式干预、中医技术循证医学、专家共识无限制B,C中等质量
中国老年学和老年医学学会[28]2025中国指南心律失常单病生活方式干预、中医慢性病管理循证医学无限制B,C中等质量
中国心血管病风险评估和管理指南编写联合委员会[29]2019中国指南心血管病共病生活方式干预循证医学无限制C中等质量
SIGN[30]2025英国指南2型糖尿病单病数字健康管理、健康教育证据为基础无限制A,C中等质量
NICE[31]2025英国指南慢性阻塞性肺疾病单病数字健康技术证据为基础无限制A中等质量
NICE[32]2023英国指南脑卒中单病数字健康技术证据为基础无限制A中等质量
NICE[33]2022英国指南2型糖尿病单病健康教育证据为基础无限制C中等质量
NICE[34]2015英国指南慢性病不限定行为与生活方式干预证据为基础无限制C中等质量
SIGN[35]2017英国指南糖尿病单病生活方式、健康教育证据为基础无限制C高质量
中华医学会健康管理学分会[36]2024中国专家共识糖尿病单病5G智能可穿戴设备循证医学无限制A中等质量
中国心血管健康联盟高血压达标中心等[37]2022中国专家共识高血压单病互联网+未注明院外A中等质量
北京护理学会心血管专业委员会[38]2022中国专家共识冠心病单病健康教育证据为基础无限制C高质量
中国老年保健协会糖尿病专业委员会等[39]2021中国专家共识糖尿病单病互联网医院未注明无限制A低质量
中华医学会全科医学分会等[40]2025中国专家共识不限制疾病不限制互联网医疗健康服务未注明院外A中等质量
中国女医师协会糖尿病专业委员会[41]2022中国专家共识糖尿病单病筛查及干预未注明院内C中等质量
中国微循环学会糖尿病与微循环专业委员会等[42]2022中国专家共识糖尿病单病运动干预未注明无限制C中等质量
刘靖等[43]2022中国专家共识中青年血压单病智能可穿戴设备ANSI/AAMI/ISO、AAMI/ESH/ISO无限制A中等质量
高洪伟[44]2020中国专家共识糖尿病单病远程管理证据为基础院外A中等质量
中国心血管疾病患者居家康复专家共识编写组[45]2022中国专家共识心血管疾病共病居家康复AACVPR、AHA、ACC院外C中等质量
Alenazi等[46]2020沙特阿拉伯专家共识2型糖尿病单病远程医疗程序德尔菲法无限制A中等质量
Huber等[47]2022瑞士专家共识2型糖尿病单病自我管理教育和支持德尔菲法无限制C高质量
Cebrián-Cuenca等[48]2023西班牙专家共识2型糖尿病单病健康管理德尔菲法无限制C中等质量
Abdel-Aal等[49]2022英国专家共识呼吸系统疾病单病初级健康保健德尔菲法无限制C中等质量
Moreels等[50]2023比利时专家共识慢性病不限定自我管理德尔菲法无限制C中等质量
European Society of Cardiology等[51]2024意大利专家共识慢性病不限定移动健康未注明无限制A中等质量
Barnett等[52]2024澳大利亚专家共识慢性病不限定数字医疗服务德尔菲法无限制A中等质量
Riddell等[53]2017国际（多国家）专家共识1型糖尿病单种运动管理、行为与生活方式干预证据为基础无限制C中等质量
胡大一等[54]2010中国专家共识2型糖尿病共病生活方式干预证据为基础院内C中等质量
中华医学会糖尿病学分会糖尿病教育与管理学组[55]2017中国专家共识2型糖尿病单种行为与生活方式干预循证医学无限制C中等质量
“中医推拿治疗膝骨关节炎技术规范研究”课题组[56]2020中国专家共识膝骨关节炎单病中医推拿技术循证医学院内B中等质量
Davies等[57]2022美国、欧洲专家共识2型糖尿病单病数字健康技术、健康管理技术循证医学无限制A,C中等质量
中国医疗保健国际交流促进会心血管病学分会[58]2022中国专家共识高血压、冠心病共病生活方式干预、远程管理循证医学无限制A,C中等质量
中国肺康复护理联盟肺康复护理专家共识组[59]2020中国专家共识慢性呼吸疾病共病护理综合干预循证医学、专家函询、临床经验无限制B,C中等质量
Hu等[60]2024中国最佳证据2型糖尿病单病互联网+护理服务证据为基础无限制A中等质量
GB/T 46401—2025[61]中国国家标准认知障碍单种行为与生活方式干预未注明院外C
DB36/T 2101—2024[62]中国地方标准高血压单种健康教育未注明无限制C
DB36/T 2102—2024[63]中国地方标准慢性心力衰竭单种健康教育未注明无限制C
DB52/T 1642—2021[64]中国地方标准慢性肾脏病单种健康教育未注明无限制C
DB44/T 2574—2024[65]中国地方标准卵巢癌幸存者单种中医健康管理未注明无限制B
DB44/T 2675—2025[66]中国地方标准心肌梗死单种中医健康管理未注明无限制B
DB44/T 2328—2021[67]中国地方标准慢性肾脏病单种中医健康管理未注明无限制B
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作者/年份/标准编号国家文献类型疾病病种适宜技术类型证据来源应用场景技术类别质量评价
樊长征等[8]2020中国指南慢性阻塞性肺疾病单病中医文献院内B中等质量
李建生[9]2020中国指南慢性阻塞性肺疾病单病中医康复证据为基础无限制B中等质量
中华医学会糖尿病学分会[10]2021中国指南2型糖尿病单病预防策略、健康教育与管理未注明无限制C中等质量
郭立新等[11]2024中国指南2型糖尿病单病运动治疗证据为基础无限制C高质量
顾东风等[12]2020中国指南心血管代谢疾病共病生活方式证据为基础无限制C中等质量
中华预防医学会糖尿病预防与控制专业委员会[13]2025中国指南糖尿病单病行为与生活方式干预证据为基础无限制C中等质量
郑丽等[14]2024中国指南脑卒中后偏瘫单病中医适宜技术证据为基础无限制B中等质量
Cohen等[15]2016美国指南头颈癌单种行为与生活方式干预NCCN、ASCO无限制C中等质量
Howell等[16]2011加拿大指南癌症单种行为与生活方式干预证据为基础无限制C高质量
Humphris[17]2016英国指南头颈部癌症单种行为与生活方式干预证据为基础无限制C中等质量
中华医学会心血管病分会等[18]2017中国指南心血管代谢性共病共病健康教育、行为与生活方式干预证据为基础院外C中等质量
吴兆苏等[19]2014中国指南高血压单种行为与生活方式干预证据为基础无限制C中等质量
王文[20]2015中国指南高血压单种健康教育、生活方式干预证据为基础无限制C中等质量
世界中医药学会联合会肺康复专业委员会[21]2020中国指南慢性阻塞性肺疾病单病中医康复技术循证医学无限制B中等质量
中医康复医学会中西医结合专业委员会中医康复学组[22]2021中国指南缺血性脑卒中单病中医康复技术循证医学无限制B中等质量
Rippe[23]2025美国指南2型糖尿病共病生活方式干预循证医学无限制C中等质量
Jain等[24]2022加拿大指南心血管疾病单病健康行为干预循证医学无限制C中等质量
SIGN[25]2017英国指南心脏疾病共病综合康复干预循证医学、专家意见无限制A,C中等质量
中国老年学和老年医学学会[26]2023中国指南2型糖尿病单病生活方式干预、中医适宜技术循证医学无限制B,C中等质量
中国老年学和老年医学学会[27]2022中国指南缺血性脑卒中单病生活方式干预、中医技术循证医学、专家共识无限制B,C中等质量
中国老年学和老年医学学会[28]2025中国指南心律失常单病生活方式干预、中医慢性病管理循证医学无限制B,C中等质量
中国心血管病风险评估和管理指南编写联合委员会[29]2019中国指南心血管病共病生活方式干预循证医学无限制C中等质量
SIGN[30]2025英国指南2型糖尿病单病数字健康管理、健康教育证据为基础无限制A,C中等质量
NICE[31]2025英国指南慢性阻塞性肺疾病单病数字健康技术证据为基础无限制A中等质量
NICE[32]2023英国指南脑卒中单病数字健康技术证据为基础无限制A中等质量
NICE[33]2022英国指南2型糖尿病单病健康教育证据为基础无限制C中等质量
NICE[34]2015英国指南慢性病不限定行为与生活方式干预证据为基础无限制C中等质量
SIGN[35]2017英国指南糖尿病单病生活方式、健康教育证据为基础无限制C高质量
中华医学会健康管理学分会[36]2024中国专家共识糖尿病单病5G智能可穿戴设备循证医学无限制A中等质量
中国心血管健康联盟高血压达标中心等[37]2022中国专家共识高血压单病互联网+未注明院外A中等质量
北京护理学会心血管专业委员会[38]2022中国专家共识冠心病单病健康教育证据为基础无限制C高质量
中国老年保健协会糖尿病专业委员会等[39]2021中国专家共识糖尿病单病互联网医院未注明无限制A低质量
中华医学会全科医学分会等[40]2025中国专家共识不限制疾病不限制互联网医疗健康服务未注明院外A中等质量
中国女医师协会糖尿病专业委员会[41]2022中国专家共识糖尿病单病筛查及干预未注明院内C中等质量
中国微循环学会糖尿病与微循环专业委员会等[42]2022中国专家共识糖尿病单病运动干预未注明无限制C中等质量
刘靖等[43]2022中国专家共识中青年血压单病智能可穿戴设备ANSI/AAMI/ISO、AAMI/ESH/ISO无限制A中等质量
高洪伟[44]2020中国专家共识糖尿病单病远程管理证据为基础院外A中等质量
中国心血管疾病患者居家康复专家共识编写组[45]2022中国专家共识心血管疾病共病居家康复AACVPR、AHA、ACC院外C中等质量
Alenazi等[46]2020沙特阿拉伯专家共识2型糖尿病单病远程医疗程序德尔菲法无限制A中等质量
Huber等[47]2022瑞士专家共识2型糖尿病单病自我管理教育和支持德尔菲法无限制C高质量
Cebrián-Cuenca等[48]2023西班牙专家共识2型糖尿病单病健康管理德尔菲法无限制C中等质量
Abdel-Aal等[49]2022英国专家共识呼吸系统疾病单病初级健康保健德尔菲法无限制C中等质量
Moreels等[50]2023比利时专家共识慢性病不限定自我管理德尔菲法无限制C中等质量
European Society of Cardiology等[51]2024意大利专家共识慢性病不限定移动健康未注明无限制A中等质量
Barnett等[52]2024澳大利亚专家共识慢性病不限定数字医疗服务德尔菲法无限制A中等质量
Riddell等[53]2017国际（多国家）专家共识1型糖尿病单种运动管理、行为与生活方式干预证据为基础无限制C中等质量
胡大一等[54]2010中国专家共识2型糖尿病共病生活方式干预证据为基础院内C中等质量
中华医学会糖尿病学分会糖尿病教育与管理学组[55]2017中国专家共识2型糖尿病单种行为与生活方式干预循证医学无限制C中等质量
“中医推拿治疗膝骨关节炎技术规范研究”课题组[56]2020中国专家共识膝骨关节炎单病中医推拿技术循证医学院内B中等质量
Davies等[57]2022美国、欧洲专家共识2型糖尿病单病数字健康技术、健康管理技术循证医学无限制A,C中等质量
中国医疗保健国际交流促进会心血管病学分会[58]2022中国专家共识高血压、冠心病共病生活方式干预、远程管理循证医学无限制A,C中等质量
中国肺康复护理联盟肺康复护理专家共识组[59]2020中国专家共识慢性呼吸疾病共病护理综合干预循证医学、专家函询、临床经验无限制B,C中等质量
Hu等[60]2024中国最佳证据2型糖尿病单病互联网+护理服务证据为基础无限制A中等质量
GB/T 46401—2025[61]中国国家标准认知障碍单种行为与生活方式干预未注明院外C
DB36/T 2101—2024[62]中国地方标准高血压单种健康教育未注明无限制C
DB36/T 2102—2024[63]中国地方标准慢性心力衰竭单种健康教育未注明无限制C
DB52/T 1642—2021[64]中国地方标准慢性肾脏病单种健康教育未注明无限制C
DB44/T 2574—2024[65]中国地方标准卵巢癌幸存者单种中医健康管理未注明无限制B
DB44/T 2675—2025[66]中国地方标准心肌梗死单种中医健康管理未注明无限制B
DB44/T 2328—2021[67]中国地方标准慢性肾脏病单种中医健康管理未注明无限制B
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慢性病照护适宜技术的标准、指南和专家共识：范围审查
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尹梅华 , 段熠 , 孙宏玉 *, *
护理研究 | 慢病专题 2026,40(13): 2193-2203
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护理研究 |慢病专题 2026 , 40 (13) : 2193 -2203
慢性病照护适宜技术的标准、指南和专家共识：范围审查
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尹梅华, 段熠, 孙宏玉*, *
作者信息
  • 1北京大学护理学院，北京 100191
通讯作者:
孙宏玉，E-mail：
SUN Hongyu, E-mail:
作者简介:

尹梅华，主管护师，博士研究生

Standards, guidelines, and expert consensus on appropriate technologies for chronic disease care: a scoping review
Meihua YIN, Yi DUAN, Hongyu SUN
Affiliations
  • 1School of Nursing, Peking University, Beijing 100191 China
出版时间: 2026-07-10 doi: 10.12102/j.issn.1009-6493.2026.13.001
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摘要
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目的

对慢性病照护适宜技术的相关标准、指南及专家共识进行范围审查，为医务工作者在慢性病病人健康照护实践中提供参考。

方法

依据范围审查方法学框架，系统检索中国知网、万方数据知识服务平台、维普中文科技期刊、中国生物医学文献数据库、PubMed、Web of Science、EMbase、CINAHL、Cochrane Library、全球指南实施联盟（GIN）、英国国家卫生与临床优化研究所（NICE）、苏格兰校际指南网络（SIGN）、世界卫生组织（WHO）网站、UpToDate、医脉通15个中英文数据库，并补充检索国家及地区标准信息服务平台。检索时限为建库至2025年9月30日，对纳入文献进行系统筛选、整理与分析。

结果

共纳入60篇文献，包括指南 28 篇、专家共识24篇、最佳证据总结1篇、标准7篇，聚焦糖尿病、高血压、脑卒中、慢性阻塞性肺病等常见慢性病；归纳出三大类慢性病照护适宜技术，即数字健康技术（含网络服务、远程交互、移动应用、智能感知）、中医适宜技术（含中医外治、中医运动）、健康管理技术（含行为与生活方式干预、心理与社会支持、整体照护）。

结论

当前慢性病照护适宜技术已初步形成涵盖数字健康、传统医学和健康管理等多元化技术体系。未来应加强各类技术的整合应用与本土化实践，构建标准化的评价体系与推广机制，从而系统化提升慢性病照护质量。

慢性病  /  照护  /  适宜技术  /  标准  /  指南  /  专家共识  /  范围审查
Objective

To conduct a scoping review of relevant standards,guidelines,and expert consensus on appropriate technologies for chronic disease care,so as to provide references for healthcare professionals in the health care practice of patients with chronic diseases.

Methods

Following the methodological framework of scoping reviews,15 Chinese and English databases including CNKI,Wanfang Data,VIP,SinoMed,PubMed,Web of Science,EMbase,CINAHL,Cochrane Library,Guidelines International Network(GIN),National Institute for Health and Care Excellence(NICE),Scottish Intercollegiate Guidelines Network(SIGN),World Health Organization(WHO) website,UpToDate,and Medlive were systematically searched,supplemented by a search of national and regional standards information service platforms.The search period spanned from the establishment of each database to September 30,2025. The included literature was systematically screened,organized,and analyzed.

Results

A total of 60 articles were included,comprising 28 guidelines,24 expert consensuses,1 best evidence summary,and 7 standards.These focused on common chronic diseases such as diabetes,hypertension,stroke,and chronic obstructive pulmonary disease.Three main categories of appropriate technologies for chronic disease care were identified:digital health technologies(including network services,remote interaction,mobile applications,and intelligent sensing),appropriate traditional Chinese medicine technologies(including external treatments and therapeutic exercises),and health management technologies(including behavioral and lifestyle interventions,psychological and social support,and holistic care).

Conclusions

Current appropriate technologies for chronic disease care have initially formed a diversified technological system covering digital health,traditional medicine,and health management.Future efforts should focus on enhancing the integrated application and localized practice of various technologies,and establishing standardized evaluation systems and promotion mechanisms to systematically improve the quality of chronic disease care.

chronic disease  /  care  /  appropriate technology  /  standard  /  guideline  /  expert consensus  /  scoping review
尹梅华, 段熠, 孙宏玉. 慢性病照护适宜技术的标准、指南和专家共识：范围审查. 护理研究, 2026 , 40 (13) : 2193 -2203 . DOI: 10.12102/j.issn.1009-6493.2026.13.001
Meihua YIN, Yi DUAN, Hongyu SUN. Standards, guidelines, and expert consensus on appropriate technologies for chronic disease care: a scoping review[J]. Chinese Nursing Research, 2026 , 40 (13) : 2193 -2203 . DOI: 10.12102/j.issn.1009-6493.2026.13.001
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慢性非传染性疾病已成为全球疾病与死亡负担的主要构成因素，占全球总死亡和残疾负担的近2/3[1]。在我国，心脑血管疾病、癌症、慢性呼吸系统疾病和代谢性疾病4类慢性病导致的死亡人数占总死亡人数的88.5%，相关疾病负担占比超过84.9%[2]。随着人口老龄化进程加快，慢性病病人数量持续增长，其长期生存状态往往伴随功能受限和生活质量下降，不仅严重影响个体健康结局，也对医疗卫生系统和社会照护体系造成持续压力[3]。延长慢性病病人的生存周期并提升其生活质量，已成为慢性病防控与健康服务体系建设的重要目标，而这一目标的实现不仅依赖疾病治疗，更有赖于系统化、连续性和规范化的健康照护支持[4]。然而，目前我国慢性病管理仍以医疗干预为主，普遍存在“重治疗、轻照护”的现象，慢性病照护在实施路径、技术选择及质量控制等方面差异较大，标准化与规范化水平不足，难以满足慢性病病人长期健康管理和生活质量改善的实际需求[5]。近年来，围绕慢性病照护的适宜技术研究逐渐增多，涵盖照护干预方法、管理模式及信息化与智能健康工具等多个方面，但相关研究多分散于不同疾病或应用场景，尚缺乏基于技术标准、指南和专家共识的系统整合与综合评价，现有证据在技术适用性、实施要素及推广价值等方面仍存在不一致和不明确之处。技术标准、指南和专家共识作为规范临床实践和健康照护的重要依据，其内容的系统梳理与证据整合对于提升慢性病照护质量、促进照护同质化具有重要意义。为弥补这一缺口，本研究拟通过范围审查方法对相关证据进行系统梳理，构建一套多元化的慢性病照护适宜技术体系，为国内外慢性病健康照护实践提供科学依据与实施参考，同时为标准制定和政策规划提供理论支持。
1　资料与方法
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1.1　文献检索
采用主题词、题名词及自由词相结合的方式，系统检索中国知网、万方数据知识服务平台、维普中文科技期刊、中国生物医学文献数据库、PubMed、Web of Science、EMbase、CINAHL、Cochrane Library、全球指南实施联盟（Global Implementation Network，GIN）、英国国家卫生与临床优化研究所（National Institute for Health and Care Excellence，NICE）官网、苏格兰校际指南网络（Scottish Intercollegiate Guidelines Network，SIGN）官网、世界卫生组织（World Health Organization，WHO）官网、UpToDate、医脉通等15个中英文数据库及国家和地区标准信息服务平台。检索策略根据不同数据库的特点进行相应调整，检索时限为各数据库建库至2025年9月30日。
以中国知网为例，中文检索策略如下：
#1 SU=‘慢性病’ OR SU=‘慢性疾病’ OR SU=‘慢性非传染性疾病’ OR SU=‘长期照护’ OR SU=‘高血压’ OR SU=‘癌症’ OR SU=‘冠心病’ OR SU=‘心血管疾病’ OR SU=‘糖尿病’ OR SU=‘脑卒中’ OR SU=‘中风’ OR SU=‘慢性阻塞性肺疾病’OR SU=‘慢阻肺’ OR SU=‘COPD’
#2 SU=‘适宜技术’ OR SU=‘适用技术’ OR SU=‘适宜方法’ OR SU=‘适宜手段’ OR SU=‘管理’ OR SU=‘自我管理’ OR SU=‘照护’ OR SU=‘健康教育’ OR SU=‘病人教育’ OR SU=‘最佳实践’ OR SU=‘社区护理’ OR SU=‘居家护理’ OR SU=‘八段锦’ OR SU=‘太极’ OR SU=‘六字诀’ OR SU=‘易筋经’ OR SU=‘五禽戏’ OR SU=‘艾灸’ OR SU=‘穴位贴敷’ OR SU=‘耳穴压豆’ OR SU=‘推拿’ OR SU=‘中药熏洗’ OR SU=‘中药足浴’ OR SU=‘刮痧’ OR SU=‘拔罐’
#3 TI=‘指南’ OR TI=‘专家共识’ OR TI=‘共识’ OR TI=‘指导原则’
#4 #1 AND #2 AND #3
以PubMed为例，英文检索策略如下：
#1 "chronic disease"[Title/Abstract] OR "chronic diseases"[Title/Abstract] OR "disease chronic"[Title/Abstract] OR "chronic illness"[Title/Abstract] OR "chronic illnesses"[Title/Abstract] OR "illness chronic"[Title/Abstract] OR "chronically ill"[Title/Abstract] OR "chronic condition"[Title/Abstract] OR "chronic conditions"[Title/Abstract] OR "condition chronic"[Title/Abstract] OR "hypertension"[Title/Abstract] OR "coronary heart disease"[Title/Abstract] OR "cancer"[Title/Abstract] OR "malignancy"[Title/Abstract] OR "carcinoma"[Title/Abstract] OR "cardiovascular disease"[Title/Abstract] OR "diabetes mellitus"[Title/Abstract] OR "stroke"[Title/Abstract] OR "chronic obstructive pulmonary disease"[Title/Abstract] OR "COPD"[Title/Abstract]
#2 "appropriate technology"[Title/Abstract] OR "suitable technology"[Title/Abstract] OR "appropriate technique"[Title/Abstract] OR "applicable technology"[Title/Abstract] OR "self⁃management"[Title/Abstract] OR "patient education"[Title/Abstract] OR "nursing care"[Title/Abstract] OR "supportive care"[Title/Abstract] OR "caregiver support"[Title/Abstract] OR "remote monitoring"[Title/Abstract] OR "telecare"[Title/Abstract] OR "appropriate technolog*"[Title/Abstract] OR "best practice*"[Title/Abstract] OR "Baduanjin"[Title/Abstract] OR "Taiji"[Title/Abstract] OR "six⁃character formula"[Title/Abstract] OR "yijin jing"[Title/Abstract] OR "Wuqinxi"[Title/Abstract] OR "moxibustion"[Title/Abstract] OR "acupoint application"[Title/Abstract] OR "auricular plaster therapy"[Title/Abstract] OR "Tuina"[Title/Abstract] OR (("herbal medicine"[MeSH Terms] OR ("Herbal"[All Fields] AND "medicine"[All Fields]) OR "herbal medicine"[All Fields] OR "herbalism"[All Fields] OR "Herbal"[All Fields] OR "herbals"[All Fields]) AND "Washing"[Title/Abstract]) OR "herbal foot bath"[Title/Abstract] OR "gua sha"[Title/Abstract] OR "cupping"[Title/Abstract]
#3 "guideline"[Title/Abstract] OR "consensus"[Title/Abstract] OR "practice guideline"[Title/Abstract] OR "Delphi technique"[Title/Abstract] OR "expert consensus"[Title/Abstract]
#4 #1 AND #2 AND #3
1.2　文献纳入与排除标准
根据PCC原则制定纳入标准。1)研究对象(population)：慢性病病人(如高血压、糖尿病、心血管疾病、慢性阻塞性肺疾病、肿瘤、脑卒中等)；2)概念(concept)：聚焦于慢性病照护适宜技术[6-7](WHO定义：具有科学、有效的方法、程序、技术和设备，这些技术应当能够适应当地的需求，被使用者及服务对象所接受，并且能够利用社区或国家可负担的资源进行维护和应用)；3)情境(context)：医院、社区、养老机构、居家照护等多种照护环境。排除标准：1)原始研究、综述、评论、社论、会议论文等非指南类文献；2)药物治疗与其他诊疗技术为主，未涉及护理/照护技术的指南；3）非中英文及无法获取全文的文献。
1.3　文献筛选与数据提取
使用EndNote 20软件对检索到的文献进行去重处理后，再由2名研究人员依据纳入与排除标准针对文献题目及摘要独立开展初步筛选，接着阅读全文进行二次筛选。筛选过程中，如遇分歧，由第3名研究人员介入协商，确定最终纳入研究的文献。
根据预先设计的数据提取表格使用Excel软件进行数据提取，必要时研究者与原文作者联系以获取详细信息。数据提取内容包括：作者、发表年份、国家、文献来源、疾病名称、病种类型、适宜技术类型、证据来源、质量评估、应用场景及技术类别。
2　结果
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2.1　文献筛选结果及纳入文献的基本特征
初步检索获得13 511篇文献，依据纳入及排除标准进行筛选，最终共纳入60篇文献，其中指南28篇[8-35]、专家共识24篇[36-59]、最佳证据总结1篇[60]、标准7篇[61-67]，覆盖中国、美国、英国、西班牙、加拿大、意大利、比利时、澳大利亚等多个国家；聚焦的慢性病包括糖尿病、高血压、冠心病、脑卒中、慢性心力衰竭、心肌梗死、心血管共病、慢性阻塞性肺疾病、癌症、慢性肾脏病、认知障碍等疾病。文献筛选的流程图详见图1。
质量评价由4名研究者独立完成。评价前，所有研究者均接受统一系统培训及实践练习，以确保对评价标准理解的一致性。为降低评价偏倚风险，采用随机顺序对纳入的指南、专家共识及最佳证据进行独立评价；如遇重大分歧，通过咨询循证方法学专家协商解决。指南质量评价采用临床指南研究与评价系统（appraisal of guidelines for research & evaluation，AGREE）Ⅱ评估工具，该工具包含6个领域、共23个条目及2个总体评价条目，得分越高表示指南的方法学质量越高[68]；专家共识质量评价采用澳大利亚乔安娜·布里格斯研究所（Joanna Briggs Institute，JBI）循证卫生保健中心发布的专家共识评价工具（2016版）[69]；最佳证据质量评价采用澳大利亚JBI循证中心证据分级及证据推荐级别系统（2014版）对纳入证据进行等级划分[70]。最终评价结果依据质量等级进行归类，并以高质量、中等质量和低质量进行呈现。纳入文献基本特征及质量评价见表1。
2.2　慢性病照护适宜技术特征
本研究系统总结了慢性病照护的数字健康技术、中医适宜技术、健康管理技术三大适宜技术维度。研究表明，现代慢性病照护已从单一技术应用发展为多维度、多整合、多学科的协同健康照护体系，强调各类技术在疾病管理全过程中的协同与互补。慢性病照护适宜技术特征见图2。
2.2.1　数字健康技术
2.2.1.1　网络服务
依托互联网平台、信息系统与应用程序编程接口（API）实现健康信息的高效传输、安全存储与便捷交互，构建起完整的网络服务体系[37]。在此基础上，“互联网+慢性病”模式已在高血压院外管理及糖尿病线上管理领域广泛应用[37,39,44]。与此同时，基于5G的糖尿病健康管理可进一步提升血糖控制效果，“家庭医生+互联网”模式则让优质医疗健康服务变得触手可及[37,39,44]。
2.2.1.2　远程交互
借助视频、语言和图像传输技术，即使医患双方不在同一地方也能实现实时或异步的远程交流[44]。该方案已广泛用于慢性阻塞性肺疾病、糖尿病以及癌症病人的居家照护[31,44,50]。实践表明，远程管理不仅能提升糖尿病控制达标率，也能显著改善慢性阻塞性肺疾病病人的医疗服务质量。
2.2.1.3　移动应用
借助APP、小程序和系统推送功能为慢性病病人提供个性化、随身式的健康服务[36]。移动健康技术已全面融入慢性病病人的症状管理和异常值监测，正升级为慢性病病人的“移动健康管家”。研究显示，“Active+me R EMOTE”APP通过微课和互动运动视频提供阶梯式教育项目，让居家慢性阻塞性肺疾病病人在家就能完成自我管理，随着病人健康水平和运动能力提升，课程难度自动增加，实现真正的“因人制宜”[31,44,50]。
2.2.1.4　智能感知
凭借测量精准、云端协同与预警推送，智能可穿戴设备已被广泛用于慢性病照护的动态监测与风险预警；配合短信提醒、应用推送与在线课程，实现知识传递与行为干预，共同构建慢性病管理的智能化守护体系[60]。此外，基于智能手环、腕带、手表、眼镜、服饰等可穿戴设备，可为高血压病人提供连续、精准的管理支持[43]。
由此可见，数字健康技术通过网络化、移动化与智能化手段，将传统间断式慢性病照护转变为连续、动态和可反馈的管理模式，为慢性病病人提供了跨时空的健康支持，也为护理人员实施远程评估与精准干预提供了技术支持。
2.2.2　中医适宜技术
2.2.2.1　中医外治
经络外治技术是以针灸、推拿、拔罐、刮痧等的常用中医技术[8-9,14,65-67]。研究发现，以膻中、肺俞、足三里等为主的针灸疗法，在慢性阻塞性肺疾病、脑卒中恢复期病人中疗效较好[14]。与此同时，推拿/按摩疗法在脑卒中病人病情稳定期使用，可改善病人的吞咽功能及肢体功能。
2.2.2.2　中医运动
传统功法是以八段锦、五禽戏、太极拳、六字诀等为主的传统锻炼方式[8-9,14,65-67]。八段锦已被证实可改善脑卒中后轻度认知障碍，五禽戏可改善脑梗死病人的运动功能，太极拳能改善脑卒中病人的平衡能力。此外，多种中医运动被证实为肺康复的有效适宜技术。中医适宜技术以操作简便、病人依从性高和长期干预可行性强为特点，在慢性病功能恢复与症状改善中发挥独特优势，尤其适用于社区及居家照护场景，体现了“简、便、效、廉”的适宜技术理念。
2.2.3　健康管理技术
2.2.3.1　行为与生活方式
行为与生活方式涵盖运动[12,42,53]、饮食[55]、健康教育[38,62-64]及生活方式[12-13]等多类干预手段。运动干预已被确立为糖尿病管理的核心适宜技术之一，相关专家共识进一步细化了胰岛素剂量调整算法及运动后低血糖风险预警机制[10-11,36,42,44,55]；而对于心血管代谢疾病，其防治指南则提出了整合饮食、戒烟、限酒、睡眠与体重的“健康五件套”综合干预策略[12,18,45,54]。
2.2.3.2　心理与社会支持
心理与社会支持涵盖心理支持[17]、社会支持[16,61]、情绪管理及家属参与[48]等多类干预手段。在不同慢性病的健康照护指南中，这些支持手段被具体化、系统化应用。在高血压教育指南中，提出以“生物反馈-渐进式放松-认知重建”为核心的三步法情绪管理策略，帮助病人调节情绪和改善血压控制；糖尿病综合管理共识将家庭血压与血糖协同监测纳入评估体系，体现了从病人到家庭、社区的延续性健康照护理念[10]。
2.2.3.3　整体照护
整体照护适宜技术涵盖护理干预[71]、康复训练[45]及随访管理[41]等一系列综合性照护措施。在具体实践中，整体照护适宜技术朝着更精细、更综合的方向发展。通过脑卒中家庭护理协议与慢性病管理指南，构建了贯穿“住院教育-出院计划-社区随访”闭环管理模式[71]；社区心血管疾病防治指南提出基于“红黄绿”三色风险分级的差异化随访策略[18]；糖尿病远程管理共识确立了护士主导的线上个案管理工作清单[46]。整体照护不仅丰富了随访管理的实践维度，也深化了其综合理念。
总体而言，慢性病照护适宜技术已不再局限于单一干预手段，而是呈现出以病人需求为导向、以多技术协同为特征的发展趋势。数字健康技术侧重于提升照护的可及性与连续性，中医适宜技术强调功能恢复与长期调养，而健康管理技术则聚焦行为改变与照护整合。三类技术在慢性病管理不同阶段发挥互补作用，共同构建覆盖“监测-干预-随访-支持”的连续性照护路径，为慢性病病人提供更具可操作性和可持续性的照护方案。
3　讨论
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3.1　慢性病注重预防与健康照护的综合管理
本研究结果显示，以四大慢性病为代表的疾病防控，应遵循“预防为主、防治结合”的核心理念[8,10]。究其原因：由于慢性病的发生与后天行为、环境因素高度相关，这意味着通过积极预防降低疾病负担、控制病程发展是实现健康效益的关键[72]。与此同时，万修伟等[73]的研究指出，健康教育与风险评估应前移至疾病前期和亚健康阶段，通过持续健康监测、早期筛查与个体化干预，实现从疾病治疗向健康促进的转变。慢性病健康照护应构建以“医防融合、医养结合”的服务体系，并强化家庭与社区在慢性病防控中的支撑作用，形成覆盖全生命周期的健康管理链条[74]。同时，部分指南提出应将慢性病照护纳入公共卫生战略，推进分级诊疗与长期照护制度建设，实现从“以治病为中心”向“以健康为中心”的系统性转变[40]。由此可见，慢性病的照护重点不应局限于治疗环节，而应聚焦疾病的早期预防与全程管理。
3.2　标准、指南与专家共识多聚焦单病种管理
从纳入文献的分布来看，当前慢性病照护适宜技术的指南与专家共识多集中于糖尿病[36]、高血压[37]、脑卒中[27]等单一病种领域，而针对心血管代谢共病、多病共存及老年综合征等复杂慢性病群体的研究仍较为有限。这种以单病种为导向的研究模式虽然有助于形成疾病特异性的照护规范，但在临床中，病人常存在多系统、多病共存的情况，单病管理策略难以满足复杂照护需求[75]。虽然文献中提及多学科协作模式或综合管理路径，但尚缺乏针对共病病人的系统性技术框架与跨病种干预标准[54]。未来应从整体健康视角出发，探索不同慢性病之间的共性照护需求，推动适宜技术在多病共管中的融合与共享，尽快实现慢性病照护模式从“单病管理”向“系统整合”的转型升级。
3.3　运动干预与运动治疗成为慢性病照护的核心技术
运动干预被纳入多数慢性病指南与共识中，已成为慢性病防控与康复的核心适宜技术之一[42]。研究显示，规律运动可改善血糖控制、降低血压、优化脂质代谢、促进心肺功能恢复，并降低慢性病并发症发生风险。Riddell等[53]编制的糖尿病指南已将运动处方纳入个体化管理的重要组成部分，明确了运动强度、频率及监测指标，甚至细化到运动后胰岛素剂量调整和低血糖风险评估。心血管指南将运动干预与饮食、体重管理、戒烟限酒并列为“五件套”，强调生活方式的综合干预价值[45]。脑卒中、慢性阻塞性肺疾病等康复指南中，运动治疗不仅促进神经功能重塑，还能改善心理状态与生活质量[9,27]。运动干预正逐渐从经验性管理走向循证化、标准化和数字化，结合可穿戴设备进行运动数据采集、实时反馈与风险预警[76]。运动治疗已成为慢性病照护适宜技术体系中的重要支柱，其科学化、个体化与智能化发展趋势将进一步提升慢性病防控的有效性与可持续性。
3.4　数字化健康技术是慢性病健康照护的发展趋势
数字健康适宜技术在慢性病照护中应用广泛且持续深化，包括互联网、远程医疗、移动健康（mHealth）、智能可穿戴设备与数字自我管理教育等[47]。研究发现，“互联网+慢性病管理”模式有效提升了病人的依从性与医护沟通效率，实现了院内外照护的无缝衔接[52]。远程医疗与移动健康技术广泛应用于糖尿病和慢性阻塞性肺疾病等病人的远程监测、健康教育与随访管理中，促进了从被动治疗向主动健康管理的转变[77]。同时，数字化自我管理教育通过短信、APP推送、在线课程等方式将健康教育融入病人的日常生活，实现了行为科学与数字技术的深度融合[51]。从地域分布来看，不同国家和地区在慢性病照护的侧重点上存在一定差异。欧美等高收入国家的指南和共识中，数字健康技术在慢性病照护中的应用更为系统化，而中国则更多关注这些技术在不同慢性病中的具体应用，反映出不同医疗体系、文化背景和资源配置模式对数字健康技术应用的差异[78]。总体而言，数字健康适宜技术正推动慢性病照护从经验型管理向数据驱动型、智能决策型方向发展，为精准健康管理提供了新的技术路径。
3.5　中医适宜技术在慢性病照护中展现独特优势
传统医学适宜技术在慢性病照护中占重要地位，尤其在呼吸系统、脑血管病及代谢性疾病领域表现突出[14,66-67]。研究发现，中医药、针灸、推拿、八段锦等技术能够在改善症状、促进康复和提升生活质量方面发挥积极作用[79]。慢性阻塞性肺疾病管理中，“辨证-汤药-膏方-穴位贴敷”模式通过个体化辨证与综合干预实现肺功能改善与病情稳定[9]；在脑卒中康复中，针灸与八段锦结合可促进神经功能恢复、缓解肌张力异常[80]。与西医的标准化治疗相比，中医适宜技术更注重康养结合与身心同治，符合慢性病长期照护的需求。未来应进一步推动中医适宜技术的循证化研究与标准化指南制定，促进中西医结合的慢性病照护模式建设，使传统中医技术在现代健康管理体系中发挥更大作用。
4　小结
收起
本研究系统梳理了国内外慢性病照护适宜技术的指南与专家共识，总结了数字健康技术、中医适宜技术、慢性病管理技术等主要类型，可为构建我国慢性病照护体系提供参考。然而，仍存在一定局限性。首先，纳入文献以中英文文献为主，可能遗漏其他语种或非正式共识文件，存在检索偏倚；其次，现有研究多聚焦单病种管理，对多病共存、老年综合征及跨病种整合照护的探讨不足，尚难全面反映慢性病照护的复杂性；第三，本研究主要基于文献分析，缺乏对适宜技术可行性、依从性与实施效果的实证研究；第四，本研究纳入了国家标准与地方标准等规范性文件，但由于目前缺乏针对标准类文献的统一质量评价工具，未能对其方法学质量进行量化评分评价，未来有必要开发或引入更适用于标准类证据的评价方法。
未来研究应加强多病共管与整合照护模式的探索，推动慢性病照护从单病管理向系统协同转变；同时，促进数字健康、传统医学与行为干预的融合创新，形成智能化、个体化、文化适配性的慢性病管理体系。应建立国家级慢性病照护技术标准与评估体系，完善循证分级与推广机制；此外，还需强化跨学科、跨机构合作，利用真实世界数据和人工智能技术，验证适宜技术的有效性与可持续性，为实现“健康中国”战略目标提供科学支撑。

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doi: 10.12102/j.issn.1009-6493.2026.13.001
  • 接收时间：2025-12-26
  • 首发时间：2026-10-30
  • 出版时间：2026-07-10
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  • 收稿日期：2025-12-26
  • 修回日期：2026-05-18
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    1北京大学护理学院，北京 100191

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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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