基于双视角调查研究的糖尿病肾病精准慢性病管理

Precise Chronic Disease Management of Diabetic Nephropathy Based on Dual-Perspective Investigation and Research

摘要: 目的：本研究采用双视角调查研究方法，从患者和医生两个角度全面了解糖尿病肾病管理的现状。基于对调研数据的系统剖析，旨在为优化糖尿病肾病患者的临床结局与生存质量构建理论依据，并提供可行的临床实践指导。方法：本研究于2024年5月至2025年5月期间，选取吉林市两家社区卫生服务中心作为调研现场，分别对97名全科医生及326名糖尿病患者进行了问卷调查，所使用的问卷为课题组自行设计。采用混合研究方法，结合定量问卷调查和定性健康教育及专业知识培训，对糖尿病患者和社区医生的认知及需求进行分析。结果：326例糖尿病患者中，仅24.85%患者知晓尿微量白蛋白是诊断早期DKD最敏感的指标；38.65%患者知晓糖尿病可并发DKD；调查对象对DKD晚期常见临床症状如高血压、蛋白尿、贫血、水肿的知晓率为26.38%。经健康宣教干预后，患者对于糖尿病肾病等并发症的认知水平与相关知识掌握程度均得到显著提升(p < 0.01)，但与预设的目标要求相比，相关认知水平仍有待进一步提高。调查数据显示，在参与调研的97名社区全科医生中，对糖尿病肾病患者糖化血红蛋白控制目标知晓的比例为64.95%。对于DKD患者血压控制目标知晓率61.86%。本研究对比分析了全科医生专业培训前后的知识储备情况，发现其对DKD等并发症及相关知识的掌握程度均有显著改善(p < 0.01)。结论：医患在疾病认知、管理目标方面存在显著差异，患者自我管理能力不足，社区全科医生在患者依从性上面临挑战。社区全科医生当前对糖尿病肾病(DKD)的认知水平与诊疗实践能力尚有进一步提升的空间。建议从全科医师、培训实施方及社区卫生管理部门三个维度发力，以此提升社区全科医生的DKD诊疗服务能力。必须加强对糖尿病患者进行DKD防治知识的健康教育，提高防治DKD的意识，以减少终末期肾功能衰竭的发生。

Abstract: Objective: This study adopts a dual-perspective investigation and research method to comprehensively understand the current situation of diabetic nephropathy management from the perspectives of both patients and doctors. Based on a systematic analysis of the research data, the aim is to establish a theoretical basis for optimizing the clinical outcomes and quality of life of patients with diabetic nephropathy, and to provide feasible clinical practice guidance. Methods: From May 2024 to May 2025, this study selected two community health service centers in Jilin City as the research sites. Questionnaires were conducted among 97 general practitioners and 326 diabetic patients respectively. The questionnaires used were designed by the research team themselves. A mixed research method was adopted, combining quantitative questionnaire surveys with qualitative health education and professional knowledge training, to analyze the cognition and needs of diabetic patients and community doctors. Results: Among 326 diabetic patients, only 24.85% were aware that urinary microalbumin was the most sensitive indicator for diagnosing early DKD. 38.65% of the patients were aware that diabetes could be complicated by DKD. The awareness rate of the survey subjects regarding common clinical symptoms in the advanced stage of DKD, such as hypertension, proteinuria, anemia and edema, was 26.38%. After health education intervention, the patients' cognitive level of complications such as diabetic nephropathy and their mastery of related knowledge were significantly improved (p < 0.01), but compared with the preset target requirements, the relevant cognitive level still needs to be further improved. Conclusions: Survey data shows that among the 97 community general practitioners who participated in the research, the proportion of those who were aware of the control targets for glycated hemoglobin in patients with diabetic nephropathy was 64.95%. The awareness rate of blood pressure control targets for DKD patients was 61.86%. This study comparatively analyzed the knowledge reserves of general practitioners before and after professional training and found that their mastery of complications such as DKD and related knowledge had significantly improved (p < 0.01). Conclusion: There are significant differences between doctors and patients in terms of disease cognition and management goals. Patients have insufficient self-management ability, and community general practitioners face challenges in patient compliance. There is still room for further improvement in the current understanding level and practical ability of diagnosis and treatment of diabetic nephropathy (DKD) among community general practitioners. It is suggested that efforts be made from three dimensions: general practitioners, training implementations and community health management departments, so as to enhance the DKD diagnosis and treatment service capabilities of community general practitioners. It is necessary to enhance health education on the prevention and treatment of DKD for diabetic patients, raise their awareness of DKD prevention and treatment, and thereby reduce the occurrence of end-stage renal failure.