The prevalence rate of type 2 diabetes is increasing in China. General practitioners play an important role in the prevention and treatment of type 2 diabetes and its complications. Chronic kidney disease (CKD) is a common co-existing disease in patients with diabetes. However, at present, there is little research evidence on type 2 diabetes combined with CKD in primary care in China.

To investigate the obstructive factors in the monitoring and management of type 2 diabetes mellitus with CKD from the perspective of general practitioners.

From May to July 2022, a one-to-half structured interview was conducted with snowball sampling among general practitioners in an urban area of Beijing, and the interview outline was formulated based on the theoretical domains framework (TDF). NVivo 11 software was used to encode and classify the interview contents. Subject frame analysis method was used to sort out and analyze the data, and extract the theme.

13 general practitioners were interviewed in this study, and the years of working in general practice ranged from 8 to 22 years. The study identified barriers related to six domains in TDF, namely knowledge/skills, beliefs about outcomes, motivation and goals, medical background, resources and norms of conduct. After refining again, the themes were lack of systematic knowledge and skills related to CKD, imperfect incentive mechanism of primary medical staff, lack of smooth referral process between primary medical institutions and higher hospitals, poor self-management ability of patients and other obstacles.

There are many factors preventing general practitioners from monitoring and managing patients with type 2 diabetes complicated with CKD in the community. It is necessary to strengthen the knowledge and skills training of general practitioners with diabetes mellitus complicated with CKD, improve the ability of general practitioners to monitor and manage CKD, improve the incentive mechanism of primary medical institutions and establish an effective referral process with superior hospitals, strengthen the health education of patients, improve the self-management ability of patients, and enhance the prevention and treatment ability of primary medical institutions with type 2 diabetes complicated with CKD.

我国2型糖尿病患病率不断升高，全科医生在2型糖尿病及其并发症防治中发挥重要作用，慢性肾脏病（CKD）是糖尿病患者常见的并存疾病，但目前我国对基层医疗中2型糖尿病合并CKD综合防治的相关研究证据较少。

基于全科医生视角了解社区在2型糖尿病合并CKD监测和管理中存在的阻碍因素。

于2022年5—7月，在北京市某城区采用滚雪球抽样法抽取全科医生进行"一对一"半结构化访谈，基于理论域框架（TDF）制订访谈提纲。采用NVivo 11软件对访谈内容进行编码、归类，采用主题框架分析法对资料进行整理、分析，并提炼主题。

本研究共访谈13名全科医生，受访者从事全科岗位工作的年限为8~22年。研究总结出与TDF中6个领域有关的阻碍因素，分别为知识/技能、对结果的信念、动机和目标、医疗背景、资源、行为规范。经过再次提炼，发现缺乏系统的CKD相关知识和技能、基层医务人员激励机制不完善、基层医疗机构与上级医院缺乏通畅转诊流程、患者自我管理能力欠佳等是社区在2型糖尿病合并CKD监测和管理中存在的阻碍因素。

全科医生在对2型糖尿病合并CKD患者的监测和管理中存在不同层面的阻碍因素，需要加强全科医生相关知识及技能培训，完善基层医疗卫生机构激励机制，建立基层医疗卫生机构与上级医院的有效转诊流程，提高患者自我管理能力，以提升基层医疗卫生机构对于2型糖尿病合并CKD的防治能力。