Accessing the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus in hospitals: a cross-sectional study using A-GIST

Accessing the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus in hospitals: a cross-sectional study using A-GIST | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Accessing the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus in hospitals: a cross-sectional study using A-GIST WANG Yanbo, Kun Zou, YANG Nan, HE Siyi, ZENG Linan, LI Hailong, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7159169/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 5 You are reading this latest preprint version Abstract Background Type 2 diabetes mellitus (T2DM) is the leading cause of morbidity and mortality in China. The 2020 Chinese clinical practice guideline for prevention and treatment of T2DM was published at April 2021, yet its status of implementation is unclear. Objective To investigate the success of implementation of the 2020 Chinese clinical practice guideline of prevention and treatment of T2DM in public hospitals in China and to identify its associated factors and barriers. Methods A cross-sectional study was conducted using the data collected from surveillance data from the National Hospital Management and Service Guide Centre of National Health Commission of China. The status of implementation was evaluated using the Guideline Implementation Success Assessment Tool (A-GIST). Descriptive analysis was conducted to explore the status and distribution of guideline implementation among regions, provinces and hospitals, and barriers of implementation. ANOVA test and logistic regression analysis were used to analyze the factors associated with guideline implementation. Significant level was set as 0.05. All statistical analyses were conducted using Stata SE 15. Results In total, 705 participants (365 health professionals and 340 patients) from 26 hospitals and 13 provinces were included. The total implementation score was 76.86 (30.25), ranging from 65.30 to 97.94 among provinces and 42.95 to 97.94 among hospitals. Univariate analysis found that east and west region, senior age, higher degree, physician or pharmacist, senior title, and tertiary hospital had higher total implementation score than their counterparts (p < 0.05). Multivariate regression analysis found middle region (β =-15.71, 95%CI: -24.32, -7.11) and nurse professionals (-16.30, -24.14, -8.45) were independently associated with lower total implementation score. Hospital/department organized learning (69.01%), literature database (53.20%), and academic conference (47.50%) were top 3 routines to access guideline. 43(11.8%) health professionals reported barriers of guideline implementation, among which influence on patient treatment choices (5.2%), impact of medical insurance (6.3%), awareness and familiarity with the guidelines (4.1%), patients’ compliance (8.2%) were top barriers in aspects of guideline-itself, environment, health professional and patient factors. Conclusion The success of implementation of the type 2 diabetes guideline was fair in hospitals in China. There was substantial difference among regions, hospitals, and health professional groups, which warranted improvement. A-GIST is a useful tool for examining the landscape of success of implementation of CPCs and informing the targets and strategies of guideline implementation interventions. Figures Figure 1 Figure 2 Figure 3 Contributions to the literature China has the largest number of patients with type 2 diabetes mellitus (T2DM) worldwide. Guideline for T2DM in China (2020) has been published to improve its management and patient outcomes, but its success of implementation is unclear. This study evaluated the success of implementation of T2DM guideline, explored its weak points among regions, hospitals and health professional groups, channels of guideline acquisition, and barriers, using the generalized Guideline Implementation Success Assessment Tool (A-GIST). The findings informed the targets setting and strategic intervention design to improve the guideline implementation, and offered benchmark of comparison of implementation success across guidelines in China and beyond. Introduction Type 2 diabetes mellitus (T2DM) causes heavy burden to individuals and society globally and in China. Diabetes was the tenth leading cause of death and the seventh leading cause of disability-adjusted life-years (DALYs) in the world, with a prevalence of about 6.1% 1–3 , of which nearly 90% are type 2 diabetes mellitus (T2DM) 4 . The International Diabetes Federation estimated that there are approximately 537 million adults suffering from diabetes, accounting for 10.5% of the adult population, forecast to reach 643 million by 2030 and 783 million by 2045. Diabetes causes health expenditures of more than 966 billion US dollars, accounting for 9% of the total adult expenditure globally 5 . China has the largest number of patients with diabetes (140.9 million adults) worldwide 5 , representing 26% of the global diabetes population. In 2021, the healthcare costs related to diabetes in China amount to 165 billion dollars 5 . Clinical practice guidelines (CPGs) are statements that include recommendations intend to optimize patient care that are informed by systematic reviews of evidence and assessment of the benefits and harms of alternative care options 6 . CPGs have been proved an effective measure to standardize clinical practice and improve quality of health care 7 8 . To curb the prevalence and burden of the disease, medical societies have published the guidelines for the diagnosis and treatment of diabetes, and the nearest version of Chinese Guideline for the Prevention and Treatment of Type 2 Diabetes Mellitus 2020 was published in 2021 9 . Understanding the success of implementation and associated factors of the clinical guideline of diabetes can inform solutions to achieving a more successful implementation of guidelines and better patients' clinical outcomes. However, the overall success of the implementation of the Chinese CPGs for T2DM is unclear. Previous studies investigated the adherence to diabetes guidelines in medical professionals or patients only in some provinces, 10 11 and involved varied aspects of diabetes management, such as nursing care, antidiabetic medications, glycemic control, patient self-monitoring, etc. 12–14 . Currently, there is still lack of knowledge on the landscape of the success of T2DM guideline implementation in public hospitals across China, its aspects of weakness and associated factors. To access the success of implementation of CPGs, a generalized Guideline Implementation Success Assessment Tool (A-GIST) was recently developed. The A-GIST was developed based on REAIM framework, consisted of five dimensions (Reach, Adoption, Implementation, Effectiveness and Maintenance) and 20 items, considering both health professionals’ and patients’ perspectives, with a total score range from 0–100, the higher the score the better the guideline has been implemented 15 . The validity and reliability of A-GIST was verified and published 16 . It is a generalized tool to assess the success of guideline implementation and feasible to compare the success of guideline implementation between regions, institutions and populations, therefore providing real-world data to inform targets and strategies aim to improve the guideline implementation 15 . Therefore, this study aimed to investigate the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus among public hospitals in China, to identify the weak points among regions, hospitals and groups of health professionals, associated factors, acquisition channels and barriers, to inform targets setting and strategies of Implementation interventions. Methods Data source and participants A cross-sectional study was conducted. We obtained and extracted surveillance data of guideline implementation in 2023 from the national hospital management and service guide center, national health commission. The surveillance purposively selected public hospitals considering regions (east, middle and west), hospital type (secondary, tertiary), category of health professional (physician, nurse and pharmacist) and patients with T2DM. Health professionals were eligible if they directly involved in healthcare of patients with T2DM. Patients were included if they were diagnosed of T2DM and receiving healthcare of the disease in the selected hospitals. Both outpatients and inpatients were eligible. The data was anonymous, consisted of demographics of the participants and their answers to the items of A-GIST revised. To meet the needs of multifactorial analysis, the estimated sample size was set at 10 times the number of influencing factors (health professionals 7, patients 4), and considering a 20% non-response rate, the minimal required sample sizes were determined as 84 healthcare professionals and 48 patients. Assessment tool: A-GIST revised The A-GIST revised was used as assessment tool (Appendix 1). With the same structure and items of the original A-GIST 15 , wording was improved for 3 items for clarity. For the item assessing patient’s quality of life, the WHO-QOL-BREF was replaced by EQ-5D-5L for improvement of validity and applicability 15 . The A-GIST revised showed good validity and reliability (Appendix 2). A-GIST also included items collecting data on barriers of guideline implementation in guideline-itself, environment, health professional and patient dimensions 15 . Variables and data management The primary outcome was total score of guideline implementation success. The secondary outcome included dimensional score regarding Reach, Adoption, Implementation, Effectiveness and Maintenance, and barriers of the guideline implementation. Factors of interest included region, institution characteristics (hospital level), demographics (age groups) and professional characteristics (health professional, professional title, work year). Two researchers conducted data cleaning using Microsoft Excel 2016 software to ensure the accuracy of the included data. They standardized and normalized the answers for each option after removing disqualified questionnaires. Disqualified questionnaires were identified based on incomplete responses to questions, including basic information, excluding skips due to logical settings within the data. Any discrepancies in the data were resolved through discussions with a third researcher who referred back to the original data. Scores across various dimensions and overall evaluations were standardized according to a predetermined scoring method to derive dimension-specific and final scores (Appendix 3) 15 . Statistical analysis Descriptive statistics was conducted using mean and standard deviation for continues variables such as total score and scores of the five dimensions. Frequency and percentage were used to describe categorical variables such as barriers of guideline implementation. Analysis of Variance (ANOVA) was used for comparisons among regions, level of hospital, and characteristic groups of health professionals, to identify targeted population that warrant implementation intervention. Multivariate liner regression analysis was conducted to examine the factors associated with the total score of guideline implementation success. Subgroup analysis by health professional were conducted. Statistical testing adopted a two-tailed approach with a significance level α = 0.05. Data analyses were performed using Stata SE 15.0 software packages. Results Characteristics of participants In total, 365 health professionals and 340 patients with T2DM from 32 hospitals and 13 provinces were included in the analysis. Among the 365 health professionals, 160 (43.8%) were from secondary hospital and 205 (56.2%) were from tertiary hospitals; the mean age was 35 (SD 8.2); 164 (44.9%) were physicians, 140 (38.4%) were nurses and 61 (16.7%) were pharmacist; the mean work year was 10.0 (SD 8.0) years. Among the 340 patients, 189 (55.6%) were female, the median age was 52.0 (IRQ: 21.0),141 (41.5%) were outpatients and 199 (58.5%) were inpatients (Table 1 ). Table 1 Characteristics of participants (healthcare professionals and patients) n/median %/SD No. of hospitals 26 No. of participants 365 Age (year) 35.8 8.2 Education ≤ High school 9 2.5% Colleague 63 17.3% Bachelor 227 62.2% Master 54 14.8% Doctorate 12 3.3% Professional Physician 164 44.9% Nurse 140 38.4% Pharmacist 61 16.7% Professional title None 29 7.9% Junior 109 29.9% Moderate 149 40.8% Senior 78 21.4% Work year 10.0 8.0 Hospital level Secondary 160 43.8% Tertiary 205 56.2% Patients No. of participants 340 Age (year) 52.0 21.0 Sex Male 151 44.4% Female 189 55.6% Education ≤ High school 206 60.6% Colleague 68 20.0% Bachelor 61 17.9% Master 3 0.9% Doctorate 2 0.6% Patient type Outpatient 141 41.5% Inpatient 199 58.5% Success of implementation The total score of implementation success was 76.86. The dimensional score was 84.38 for reach, 79.81 for adoption, 70.11 for implementation, 83.33 for effectiveness, and 75.89 for maintenance (Fig. 1 , Appendix 4). There A-GIST identified substantial variation of total score of implementation success among provinces, ranging from 64.32 (province 7) to 97.74 (province 9) (Fig. 2 ), and also large variation among hospital, ranging from 42.95 (hospital 32) to 97.94 (hospital 21) (Fig. 3 ). Factors associated with success of implementation Univariate analyses showed that the total score of implementation success was higher in east and west region (p = 0.002), senior age groups (p = 0.044), groups with higher degree (p = 0.017), physician and pharmacist (<0.001), and senior professional title groups (p = 0.003), but with no difference among work year groups or between secondary and tertiary hospitals (Table 2 ). Table 2 Implementation success score among different groups of people Variable Category N Mean SD P No. of participants 365 76.86 30.25 Region East 88 85.54 23.57 0.002 Middle 126 70.53 33.26 West 151 77.08 29.99 Age ~ 30 84 73.53 34.44 0.044 30 ~ 40 170 74.21 31.94 40 ~ 50 85 84.55 20.75 50~ 26 79.82 27.42 Degree High school 9 66.69 36.95 0.017 College 63 76.54 29.28 Bachelor 227 74.12 32.91 Master 54 87.46 15.70 Doctorate 12 90.39 5.10 Professional Physician 164 84.65 23.06 <0.001 Nurse 140 67.04 35.96 Pharmacist 61 78.46 26.82 Professional title None 29 77.44 31.99 0.003 Junior 109 69.19 35.00 Moderate 149 77.69 29.87 Senior 78 85.77 18.86 Work year < 6 85 77.23 31.42 0.475 6 ~ 10 71 71.60 34.92 10 ~ 15 106 76.76 28.96 15 ~ 25 66 80.80 25.99 ≥ 25 37 79.36 28.71 Hospital level Secondary 160 75.52 31.13 0.457 Tertiary 205 77.90 29.59 *P<0.05 Multivariate linear regression analysis showed that middle region ( β = -15.71, 95%CI: -24.32 to -7.11) and nurse professional ( β = -16.30, 95%CI: -24.14 to -8.45) were associated with lower total score of implementation success, while other factors were not associated (Table 3 ). Multivariate linear regression analysis of dimensional scores showed similar results, additionally west region was associated with lower score of implementation dimension ( β = -11.40, 95%CI: -21.29 to -1.51) and effectiveness dimension ( β = -6.01, 95%CI: -11.98 to -0.03) (Appendix 5). Further subgroup analyses by health professionals found middle region ( β= -28.72, 95%: -45.64 to -11.80) was associated with lower total score of implementation success for nurse subgroups, but no other associated factors were identified for the three professional subgroups. Table 3 Multivariate logistic regression analysis of factors associated with total implementation success score Variable β (95% CI) P Region East Comparison Middle -15.71 (-24.32 -7.11) 0.000 West -8.09 (-16.25 0.08) 0.052 Age ~30 Comparison 30 ~ 40 -4.93 (-15.63 5.77) 0.365 40 ~ 50 -2.63 (-18.25 12.98) 0.740 50~ -6.82 (-28.76 15.13) 0.542 Degree Collage below Comparison College 17.54 (-3.83 38.92) 0.107 Bachelor 4.92 (-16.34 26.19) 0.649 Master 7.31 (-15.94 30.57) 0.537 Doctorate 9.93 (-17.41 37.27) 0.475 Professional Physician Comparison Nurse -16.30 (-24.14 -8.45) 0.000 Pharmacist -4.70 (-13.57 4.17) 0.298 Professional Title None Comparison Junior -7.40 (-20.63 5.83) 0.272 Moderate 0.97 (-13.84 15.79) 0.897 Senior 4.66 (-13.37 22.69) 0.611 Work year < 6 Comparison 6 ~ 10 -0.92 (-11.29 9.45) 0.862 10 ~ 15 0.23 (-11.25 11.72) 0.968 15 ~ 25 -0.36 (-14.49 13.77) 0.960 ≥ 25 -2.30 (-20.87 16.26) 0.807 Hospital level Tertiary Comparison Secondary -4.77 (-11.87 2.32) 0.187 Acquisition channels of guideline and barriers of implementation The top three acquisition channels of guideline of health professionals were hospital/department organized learning (69.10%), literature database (53.20%), academic conference (47.50%) (Appendix 6). The top barriers of guideline implementation were influence on patient treatment choices (5.20%) at guideline dimension, impact of medical insurance (6.30%) at environment dimension, awareness and familiarity with the guideline (4.10%) at health professional dimension, and patient's compliance (8.20%) at patient dimension (Appendix 7). Discussion This study had several main findings. First, the success of implementation of T2DM guideline was fair in public hospitals in China, though 15% health professionals involved in T2DM patient healthcare still had not been reached by the guideline. Second, substantial variation of implementation success score was found between regions, hospitals and health professional characteristic groups, which indicated targeted population of guideline implementation intervention. Third, the main acquisition channels of guideline and barriers of implementation found in this study could inform design of implementation intervention. The success of implementation of T2DM guideline was fair in public hospitals in China, with the total score of 76.86 out of 100 scale. However, 15% health professionals involved in T2DM patient healthcare still had not acknowledged the guideline, which warrant attention and improvement. Among the dimensions, reach had the highest score (84.38), followed by effectiveness (83.33), indicating the impact of the guideline implementation was promising to patient’s health outcomes, health financing and quality of life. However, the dimensional score of implementations (fidelity) was the lowest (70.11), which suggested that nearly 30% patients did not have treatment fully adherent to guideline recommendations. Previous study suggested comorbidity in patients with chronic diseases may contribute to non-adherence. However, in this study the underlying reasons were of interesting but not investigated due to lack of data, and further research is warranted. In this study, large variation of implementation success score was found among regions, provinces, hospitals and health professional groups. These findings were also consistent with previous studies, which found that the physician’s adherence of guidelines was associated with geographic regions, medical specialties, level of hospitals, length of medical professionals' practice, educational background, and evidence-based medicine skills acquired in work environment 17 18 . These findings illustrated how the A-GIST tool can be used as benchmark and to identify weak points of guideline implementation and inform targets setting of implementation intervention. For example, region (middle), provinces (i.e. middle 7, west 13), hospitals (i.e. hospital 32, hospital 20) and health professional (nurse) assessed implementation success score considerably lower than the average, which warrant specific attention and can be focus of implementation intervention. The findings of acquisition channels of the guideline may inform design of implementation intervention. In this study, it was found that the top three acquisition channels of T2DM guideline were hospital or department organized leaning, literature database and academic conference. These findings suggested that leadership and organizational learning, literature database support and academic communication are vital in promoting knowledge-translation and guideline implementation into clinical practice 19 20 . Should these interventions be conducted, especially to the region, provinces, hospitals and health professional groups with low guideline implementation success score, the overall success of T2DM guideline maybe substantially improved. The findings on barriers of guideline implementation in this study can also inform design of implementation intervention. Though previous systematic reviews have well summarized barriers of guideline implementation 21 22 , it is meaningful to explore and identify main barriers of targeted guideline in specific context, so that tailored implementation intervention can be made. For example, this study found that one of the top barriers in T2DM guideline dimension – convenience of accessing guideline, is highly relevant to the Reach dimension of guideline implementation. Combining with the findings of main acquisition channels, if the electronic guideline literature database is freely available to all health professionals, the implementation of guideline may be much improved. Regarding to the health professional dimension, awareness and familiarity with guideline was the top barrier. This indicated that timely guideline training and learning of health professionals is vital in guideline implementation. Besides, in patient dimension, the top barrier of guideline implementation was patient’s compliance, which also suggested the importance of patient education. This study had several limitations. First, this study used surveillance data, some institutions faced challenges in collecting sufficient sample sizes due to constraints in the number of eligible healthcare professionals and patients, as well as varying levels of cooperation among personnel. This may have led to potential sampling bias, limiting the representativeness of the surveyed sample and the generalizability the findings. Future studies should adopt more strategic sampling approaches, ensuring that selected sites have the capacity and willingness to complete the survey, thereby minimizing resource wastage and enhancing data reliability. Second, the study relied on self-reported questionnaire data, potential response bias cannot be ruled out. Some participants might have provided socially desirable answers, overestimating guideline adherence due to perceived healthcare professional expectations or under-reporting implementation challenges due to workplace pressures. Future research could strengthen the evaluation by integrating objective health outcomes, such as control rate of HbA1c or fasting glucose. Third, a deep understanding of specific barriers, facilitators and mechanisms for a guideline implementation may enhance the implementation intervention design, for which a qualitative study may be necessary alongside the quantitative study using A-GIST. Conclusion The success of implementation of the 2020 Chinese T2DM guideline was fair in public hospitals. But there was considerable variation among regions, provinces, hospitals and health professional groups. A-GIST is a useful tool to identify the weak points of guideline implementation, main acquisition channels and barriers of implementation, to inform targets setting and design of implementation intervention for improvement. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of West China Second University Hospital, Sichuan University. Participants all had informed consent before participation. Consent for publication All authors have consent for publication. Availability of data and material Raw data cannot be provided. Competing interests The authors have no competing interests to report. Funding This study was supported by the National Health Commission Project of China (No. [2022]047). Contributions LLZ, LNZ, YBW, WQ, KZ contributed to study conception. LNZ, KZ, NY, YBW contributed to study design. All authors involved in data collection. NY, SYH conducted data management. KZ and YN performed data analysis. 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Journal of Public Health 2024;32(10):1891 − 904. doi: 10.1007/s10389-023-01949-7 Supplementary Files Appendix17.docx STROBEcrosssectionalchecklistT2DMguidelineAGIST.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Major revision 20 Mar, 2026 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 29 Jul, 2025 Editor assigned by journal 22 Jul, 2025 First submitted to journal 22 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7159169","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":492814246,"identity":"20b2ca1e-8d14-4fec-a5ef-fb42782619e2","order_by":0,"name":"WANG Yanbo","email":"","orcid":"","institution":"Beijing General Hospital of the Chinese People's Armed Police Force","correspondingAuthor":false,"prefix":"","firstName":"WANG","middleName":"","lastName":"Yanbo","suffix":""},{"id":492814247,"identity":"0ce95af0-e8cb-4f65-a60e-46d79cebb2e0","order_by":1,"name":"Kun 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"LI","middleName":"","lastName":"Hailong","suffix":""},{"id":492814252,"identity":"28c6c12d-e6a6-4551-91c4-f66a2062b2fd","order_by":6,"name":"HUANG Liang","email":"","orcid":"","institution":"Sichuan University West China Second University Hospital","correspondingAuthor":false,"prefix":"","firstName":"HUANG","middleName":"","lastName":"Liang","suffix":""},{"id":492814253,"identity":"f417d2da-068c-4822-99ba-a6cc6328b58c","order_by":7,"name":"YI Qiusha","email":"","orcid":"","institution":"Sichuan University West China Second University Hospital","correspondingAuthor":false,"prefix":"","firstName":"YI","middleName":"","lastName":"Qiusha","suffix":""},{"id":492814254,"identity":"96cee587-3b51-4aea-a48a-351fce88fb05","order_by":8,"name":"WANG Qiang","email":"","orcid":"","institution":"Medical Management Service Guidance Center NHC China","correspondingAuthor":false,"prefix":"","firstName":"WANG","middleName":"","lastName":"Qiang","suffix":""},{"id":492814255,"identity":"49beb822-d692-41d4-aaa2-b55f8df5406d","order_by":9,"name":"ZHANG Lingli","email":"","orcid":"","institution":"Sichuan University West China Second University Hospital","correspondingAuthor":false,"prefix":"","firstName":"ZHANG","middleName":"","lastName":"Lingli","suffix":""}],"badges":[],"createdAt":"2025-07-18 15:45:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7159169/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7159169/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88235618,"identity":"b71bc7fd-497b-4035-b70d-de004a826eed","added_by":"auto","created_at":"2025-08-04 10:12:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20669,"visible":true,"origin":"","legend":"\u003cp\u003eTotal and dimensional score of implementation success\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7159169/v1/e9c9ed06171764d629f23552.jpg"},{"id":88235621,"identity":"bef46a67-0bcf-4a4d-a76e-bab0b25540ff","added_by":"auto","created_at":"2025-08-04 10:12:20","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":32756,"visible":true,"origin":"","legend":"\u003cp\u003eImplementation success score among different provinces (Mean, SD)\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7159169/v1/993f713138b151f683de388c.jpg"},{"id":88235620,"identity":"1dbcdc69-beef-437d-a37e-ec3edbd7b58b","added_by":"auto","created_at":"2025-08-04 10:12:20","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":67080,"visible":true,"origin":"","legend":"\u003cp\u003eImplementation success score among different hospitals (Mean, SD)\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7159169/v1/7863c02ed730d1fff32be3bc.jpg"},{"id":88237073,"identity":"9547c9d7-073f-4fb0-a17c-4d0560e25a37","added_by":"auto","created_at":"2025-08-04 10:36:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1012424,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7159169/v1/0d71190a-a328-44d8-b949-aed8d987bf0f.pdf"},{"id":88235628,"identity":"ee77cd78-ea0a-43f7-9ab8-5a8ed632baac","added_by":"auto","created_at":"2025-08-04 10:12:20","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":353799,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix17.docx","url":"https://assets-eu.researchsquare.com/files/rs-7159169/v1/dac6c0a50d3df6dadd93c070.docx"},{"id":88235635,"identity":"2a977fe5-c886-43c3-b76d-f4daf5855bed","added_by":"auto","created_at":"2025-08-04 10:12:20","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":26336,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEcrosssectionalchecklistT2DMguidelineAGIST.docx","url":"https://assets-eu.researchsquare.com/files/rs-7159169/v1/e2d9145e4c8d106b14ece1cc.docx"}],"financialInterests":"","formattedTitle":"Accessing the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus in hospitals: a cross-sectional study using A-GIST","fulltext":[{"header":"Contributions to the literature","content":"\u003cul start=\"50\"\u003e\n \u003cli\u003eChina has the largest number of patients with type 2 diabetes mellitus (T2DM) worldwide. Guideline for T2DM in China (2020) has been published to improve its management and patient outcomes, but its success of implementation is unclear.\u003c/li\u003e\n \u003cli\u003eThis study evaluated the success of implementation of T2DM guideline, explored its weak points among regions, hospitals and health professional groups, channels of guideline acquisition, and barriers, using the generalized\u0026nbsp;Guideline Implementation Success Assessment Tool (A-GIST).\u003c/li\u003e\n \u003cli\u003eThe findings informed the targets setting and strategic intervention design to improve the guideline implementation, and offered benchmark of comparison of implementation success across guidelines in China and beyond.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eType 2 diabetes mellitus (T2DM) causes heavy burden to individuals and society globally and in China. Diabetes was the tenth leading cause of death and the seventh leading cause of disability-adjusted life-years (DALYs) in the world, with a prevalence of about 6.1%\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e, of which nearly 90% are type 2 diabetes mellitus (T2DM)\u003csup\u003e4\u003c/sup\u003e. The International Diabetes Federation estimated that there are approximately 537\u0026nbsp;million adults suffering from diabetes, accounting for 10.5% of the adult population, forecast to reach 643\u0026nbsp;million by 2030 and 783\u0026nbsp;million by 2045. Diabetes causes health expenditures of more than 966\u0026nbsp;billion US dollars, accounting for 9% of the total adult expenditure globally\u003csup\u003e5\u003c/sup\u003e. China has the largest number of patients with diabetes (140.9\u0026nbsp;million adults) worldwide\u003csup\u003e5\u003c/sup\u003e, representing 26% of the global diabetes population. In 2021, the healthcare costs related to diabetes in China amount to 165\u0026nbsp;billion dollars\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eClinical practice guidelines (CPGs) are statements that include recommendations intend to optimize patient care that are informed by systematic reviews of evidence and assessment of the benefits and harms of alternative care options\u003csup\u003e6\u003c/sup\u003e. CPGs have been proved an effective measure to standardize clinical practice and improve quality of health care\u003csup\u003e7 8\u003c/sup\u003e. To curb the prevalence and burden of the disease, medical societies have published the guidelines for the diagnosis and treatment of diabetes, and the nearest version of Chinese Guideline for the Prevention and Treatment of Type 2 Diabetes Mellitus 2020 was published in 2021 \u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e Understanding the success of implementation and associated factors of the clinical guideline of diabetes can inform solutions to achieving a more successful implementation of guidelines and better patients' clinical outcomes. However, the overall success of the implementation of the Chinese CPGs for T2DM is unclear. Previous studies investigated the adherence to diabetes guidelines in medical professionals or patients only in some provinces, \u003csup\u003e10 11\u003c/sup\u003e and involved varied aspects of diabetes management, such as nursing care, antidiabetic medications, glycemic control, patient self-monitoring, etc.\u003csup\u003e12\u0026ndash;14\u003c/sup\u003e. Currently, there is still lack of knowledge on the landscape of the success of T2DM guideline implementation in public hospitals across China, its aspects of weakness and associated factors.\u003c/p\u003e\u003cp\u003e To access the success of implementation of CPGs, a generalized Guideline Implementation Success Assessment Tool (A-GIST) was recently developed. The A-GIST was developed based on REAIM framework, consisted of five dimensions (Reach, Adoption, Implementation, Effectiveness and Maintenance) and 20 items, considering both health professionals\u0026rsquo; and patients\u0026rsquo; perspectives, with a total score range from 0\u0026ndash;100, the higher the score the better the guideline has been implemented\u003csup\u003e15\u003c/sup\u003e. The validity and reliability of A-GIST was verified and published \u003csup\u003e16\u003c/sup\u003e. It is a generalized tool to assess the success of guideline implementation and feasible to compare the success of guideline implementation between regions, institutions and populations, therefore providing real-world data to inform targets and strategies aim to improve the guideline implementation\u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e Therefore, this study aimed to investigate the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus among public hospitals in China, to identify the weak points among regions, hospitals and groups of health professionals, associated factors, acquisition channels and barriers, to inform targets setting and strategies of Implementation interventions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eData source and participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional study was conducted. We obtained and extracted surveillance data of guideline implementation in 2023 from the national hospital management and service guide center, national health commission. The surveillance purposively selected public hospitals considering regions (east, middle and west), hospital type (secondary, tertiary), category of health professional (physician, nurse and pharmacist) and patients with T2DM. Health professionals were eligible if they directly involved in healthcare of patients with T2DM. Patients were included if they were diagnosed of T2DM and receiving healthcare of the disease in the selected hospitals. Both outpatients and inpatients were eligible. The data was anonymous, consisted of demographics of the participants and their answers to the items of A-GIST revised.\u003c/p\u003e\u003cp\u003eTo meet the needs of multifactorial analysis, the estimated sample size was set at 10 times the number of influencing factors (health professionals 7, patients 4), and considering a 20% non-response rate, the minimal required sample sizes were determined as 84 healthcare professionals and 48 patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAssessment tool: A-GIST revised\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe A-GIST revised was used as assessment tool (Appendix 1). With the same structure and items of the original A-GIST\u003csup\u003e15\u003c/sup\u003e, wording was improved for 3 items for clarity. For the item assessing patient\u0026rsquo;s quality of life, the WHO-QOL-BREF was replaced by EQ-5D-5L for improvement of validity and applicability\u003csup\u003e15\u003c/sup\u003e. The A-GIST revised showed good validity and reliability (Appendix 2). A-GIST also included items collecting data on barriers of guideline implementation in guideline-itself, environment, health professional and patient dimensions \u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eVariables and data management\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The primary outcome was total score of guideline implementation success. The secondary outcome included dimensional score regarding Reach, Adoption, Implementation, Effectiveness and Maintenance, and barriers of the guideline implementation. Factors of interest included region, institution characteristics (hospital level), demographics (age groups) and professional characteristics (health professional, professional title, work year).\u003c/p\u003e\u003cp\u003eTwo researchers conducted data cleaning using Microsoft Excel 2016 software to ensure the accuracy of the included data. They standardized and normalized the answers for each option after removing disqualified questionnaires. Disqualified questionnaires were identified based on incomplete responses to questions, including basic information, excluding skips due to logical settings within the data. Any discrepancies in the data were resolved through discussions with a third researcher who referred back to the original data. Scores across various dimensions and overall evaluations were standardized according to a predetermined scoring method to derive dimension-specific and final scores (Appendix 3) \u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics was conducted using mean and standard deviation for continues variables such as total score and scores of the five dimensions. Frequency and percentage were used to describe categorical variables such as barriers of guideline implementation. Analysis of Variance (ANOVA) was used for comparisons among regions, level of hospital, and characteristic groups of health professionals, to identify targeted population that warrant implementation intervention. Multivariate liner regression analysis was conducted to examine the factors associated with the total score of guideline implementation success. Subgroup analysis by health professional were conducted. Statistical testing adopted a two-tailed approach with a significance level α\u0026thinsp;=\u0026thinsp;0.05. Data analyses were performed using Stata SE 15.0 software packages.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eCharacteristics of participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn total, 365 health professionals and 340 patients with T2DM from 32 hospitals and 13 provinces were included in the analysis. Among the 365 health professionals, 160 (43.8%) were from secondary hospital and 205 (56.2%) were from tertiary hospitals; the mean age was 35 (SD 8.2); 164 (44.9%) were physicians, 140 (38.4%) were nurses and 61 (16.7%) were pharmacist; the mean work year was 10.0 (SD 8.0) years. Among the 340 patients, 189 (55.6%) were female, the median age was 52.0 (IRQ: 21.0),141 (41.5%) were outpatients and 199 (58.5%) were inpatients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of participants (healthcare professionals and patients)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en/median\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%/SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNo. of hospitals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNo. of participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c4\"\u003e\u003cp\u003e3.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eProfessional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eProfessional title\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWork year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHospital level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNo. of participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e340\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e189\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le; High school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColleague\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.9%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoctorate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePatient type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOutpatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInpatient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSuccess of implementation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe total score of implementation success was 76.86. The dimensional score was 84.38 for reach, 79.81 for adoption, 70.11 for implementation, 83.33 for effectiveness, and 75.89 for maintenance (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Appendix 4). There A-GIST identified substantial variation of total score of implementation success among provinces, ranging from 64.32 (province 7) to 97.74 (province 9) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and also large variation among hospital, ranging from 42.95 (hospital 32) to 97.94 (hospital 21) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFactors associated with success of implementation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUnivariate analyses showed that the total score of implementation success was higher in east and west region (p\u0026thinsp;=\u0026thinsp;0.002), senior age groups (p\u0026thinsp;=\u0026thinsp;0.044), groups with higher degree (p\u0026thinsp;=\u0026thinsp;0.017), physician and pharmacist (\u0026lt;0.001), and senior professional title groups (p\u0026thinsp;=\u0026thinsp;0.003), but with no difference among work year groups or between secondary and tertiary hospitals (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eImplementation success score among different groups of people\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e76.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e30.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e85.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e23.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e70.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e~\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e73.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e34.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026thinsp;~\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e74.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u0026thinsp;~\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e20.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e79.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e27.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eDegree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e66.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e36.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e76.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e227\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e74.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e32.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e87.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15.70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoctorate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e90.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eProfessional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e84.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e23.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e67.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e78.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eProfessional title\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e69.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e85.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eWork year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.475\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026thinsp;~\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e71.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e34.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026thinsp;~\u0026thinsp;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e76.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u0026thinsp;~\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e25.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e79.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHospital level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e75.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.457\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*P\u0026lt;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMultivariate linear regression analysis showed that middle region (\u003cem\u003eβ =\u003c/em\u003e -15.71, 95%CI: -24.32 to -7.11) and nurse professional (\u003cem\u003eβ =\u003c/em\u003e -16.30, 95%CI: -24.14 to -8.45) were associated with lower total score of implementation success, while other factors were not associated (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Multivariate linear regression analysis of dimensional scores showed similar results, additionally west region was associated with lower score of implementation dimension (\u003cem\u003eβ =\u003c/em\u003e -11.40, 95%CI: -21.29 to -1.51) and effectiveness dimension (\u003cem\u003eβ =\u003c/em\u003e -6.01, 95%CI: -11.98 to -0.03) (Appendix 5). Further subgroup analyses by health professionals found middle region (\u003cem\u003eβ=\u003c/em\u003e -28.72, 95%: -45.64 to -11.80) was associated with lower total score of implementation success for nurse subgroups, but no other associated factors were identified for the three professional subgroups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate logistic regression analysis of factors associated with total implementation success score\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(95%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRegion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-15.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-24.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-7.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-8.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-16.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e~30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026thinsp;~\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-15.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.365\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026thinsp;~\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-2.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-18.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12.98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.740\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50~\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-6.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-28.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.542\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDegree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollage below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-3.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.107\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-16.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.649\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaster\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-15.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.537\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoctorate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-17.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e37.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.475\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-16.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-24.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-8.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePharmacist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-4.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-13.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.298\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional Title\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-7.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-20.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.272\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-13.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e15.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.897\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-13.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e22.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.611\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026thinsp;~\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-11.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.862\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026thinsp;~\u0026thinsp;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-11.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.968\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u0026thinsp;~\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-14.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.77)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.960\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-2.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-20.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.807\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTertiary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComparison\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-4.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c3\"\u003e\u003cp\u003e(-11.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.187\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e Acquisition channels of guideline and barriers of implementation\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The top three acquisition channels of guideline of health professionals were hospital/department organized learning (69.10%), literature database (53.20%), academic conference (47.50%) (Appendix 6). The top barriers of guideline implementation were influence on patient treatment choices (5.20%) at guideline dimension, impact of medical insurance (6.30%) at environment dimension, awareness and familiarity with the guideline (4.10%) at health professional dimension, and patient's compliance (8.20%) at patient dimension (Appendix 7).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study had several main findings. First, the success of implementation of T2DM guideline was fair in public hospitals in China, though 15% health professionals involved in T2DM patient healthcare still had not been reached by the guideline. Second, substantial variation of implementation success score was found between regions, hospitals and health professional characteristic groups, which indicated targeted population of guideline implementation intervention. Third, the main acquisition channels of guideline and barriers of implementation found in this study could inform design of implementation intervention.\u003c/p\u003e\u003cp\u003e The success of implementation of T2DM guideline was fair in public hospitals in China, with the total score of 76.86 out of 100 scale. However, 15% health professionals involved in T2DM patient healthcare still had not acknowledged the guideline, which warrant attention and improvement. Among the dimensions, reach had the highest score (84.38), followed by effectiveness (83.33), indicating the impact of the guideline implementation was promising to patient\u0026rsquo;s health outcomes, health financing and quality of life. However, the dimensional score of implementations (fidelity) was the lowest (70.11), which suggested that nearly 30% patients did not have treatment fully adherent to guideline recommendations. Previous study suggested comorbidity in patients with chronic diseases may contribute to non-adherence. However, in this study the underlying reasons were of interesting but not investigated due to lack of data, and further research is warranted.\u003c/p\u003e\u003cp\u003eIn this study, large variation of implementation success score was found among regions, provinces, hospitals and health professional groups. These findings were also consistent with previous studies, which found that the physician\u0026rsquo;s adherence of guidelines was associated with geographic regions, medical specialties, level of hospitals, length of medical professionals' practice, educational background, and evidence-based medicine skills acquired in work environment \u003csup\u003e17 18\u003c/sup\u003e. These findings illustrated how the A-GIST tool can be used as benchmark and to identify weak points of guideline implementation and inform targets setting of implementation intervention. For example, region (middle), provinces (i.e. middle 7, west 13), hospitals (i.e. hospital 32, hospital 20) and health professional (nurse) assessed implementation success score considerably lower than the average, which warrant specific attention and can be focus of implementation intervention.\u003c/p\u003e\u003cp\u003e The findings of acquisition channels of the guideline may inform design of implementation intervention. In this study, it was found that the top three acquisition channels of T2DM guideline were hospital or department organized leaning, literature database and academic conference. These findings suggested that leadership and organizational learning, literature database support and academic communication are vital in promoting knowledge-translation and guideline implementation into clinical practice\u003csup\u003e19 20\u003c/sup\u003e. Should these interventions be conducted, especially to the region, provinces, hospitals and health professional groups with low guideline implementation success score, the overall success of T2DM guideline maybe substantially improved.\u003c/p\u003e\u003cp\u003e The findings on barriers of guideline implementation in this study can also inform design of implementation intervention. Though previous systematic reviews have well summarized barriers of guideline implementation\u003csup\u003e21 22\u003c/sup\u003e, it is meaningful to explore and identify main barriers of targeted guideline in specific context, so that tailored implementation intervention can be made. For example, this study found that one of the top barriers in T2DM guideline dimension \u0026ndash; convenience of accessing guideline, is highly relevant to the Reach dimension of guideline implementation. Combining with the findings of main acquisition channels, if the electronic guideline literature database is freely available to all health professionals, the implementation of guideline may be much improved. Regarding to the health professional dimension, awareness and familiarity with guideline was the top barrier. This indicated that timely guideline training and learning of health professionals is vital in guideline implementation. Besides, in patient dimension, the top barrier of guideline implementation was patient\u0026rsquo;s compliance, which also suggested the importance of patient education.\u003c/p\u003e\u003cp\u003eThis study had several limitations. First, this study used surveillance data, some institutions faced challenges in collecting sufficient sample sizes due to constraints in the number of eligible healthcare professionals and patients, as well as varying levels of cooperation among personnel. This may have led to potential sampling bias, limiting the representativeness of the surveyed sample and the generalizability the findings. Future studies should adopt more strategic sampling approaches, ensuring that selected sites have the capacity and willingness to complete the survey, thereby minimizing resource wastage and enhancing data reliability. Second, the study relied on self-reported questionnaire data, potential response bias cannot be ruled out. Some participants might have provided socially desirable answers, overestimating guideline adherence due to perceived healthcare professional expectations or under-reporting implementation challenges due to workplace pressures. Future research could strengthen the evaluation by integrating objective health outcomes, such as control rate of HbA1c or fasting glucose. Third, a deep understanding of specific barriers, facilitators and mechanisms for a guideline implementation may enhance the implementation intervention design, for which a qualitative study may be necessary alongside the quantitative study using A-GIST.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The success of implementation of the 2020 Chinese T2DM guideline was fair in public hospitals. But there was considerable variation among regions, provinces, hospitals and health professional groups. A-GIST is a useful tool to identify the weak points of guideline implementation, main acquisition channels and barriers of implementation, to inform targets setting and design of implementation intervention for improvement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of West China Second University Hospital, Sichuan University. Participants all had informed consent before participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRaw data cannot be provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Health Commission Project of China (No. [2022]047).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLLZ, LNZ, YBW, WQ, KZ contributed to study conception. LNZ, KZ, NY, YBW contributed to study design. All authors involved in data collection. NY, SYH conducted data management. KZ and YN performed data analysis. YBW, KZ, YN wrote the first draft of the manuscript. LLZ, WQ performed study supervision and funding acquisition. All authors contributed to results interpretation, manuscript revision, read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGBD 2021 Diabetes Collaborators. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2023;402(10397):203 − 34. doi: 10.1016/s0140-6736(23)01301-6 [published Online First: 2023/06/26]\u003c/li\u003e\n\u003cli\u003eGBD 2021 Diseases and Injuries Collaborators. Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2024;403(10440):2100-32. doi: 10.1016/s0140-6736(24)00367-2 [published Online First: 2024/04/07]\u003c/li\u003e\n\u003cli\u003eGBD 2021 Diseases and Injuries Collaborators. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2024;403(10440):2133-61. doi: 10.1016/s0140-6736(24)00757-8 [published Online First: 2024/04/21]\u003c/li\u003e\n\u003cli\u003eAhmad E, Lim S, Lamptey R, et al. Type 2 diabetes. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2022;400(10365):1803-20. doi: 10.1016/S0140-6736(22)01655-5 [published Online First: 2022/11/05]\u003c/li\u003e\n\u003cli\u003eFederation ID. IDF Diabetes Atlas 10th Edition (2021). https://diabetesatlas.org/atlas/diabetes-and-kidney-disease/. Accessed 24 Jul 2024.\u003c/li\u003e\n\u003cli\u003eGraham R, Mancher M, Wolman DM, et al. Clinical practice guidelines we can trust. Washington (DC): National Academies Press (US) 2011:04–05.\u003c/li\u003e\n\u003cli\u003eChen Y, Wang C, Shang H, et al. Clinical practice guidelines in China. \u003cem\u003eBMJ\u003c/em\u003e 2018;360:j5158. doi: 10.1136/bmj.j5158 [published Online First: 2018/02/14]\u003c/li\u003e\n\u003cli\u003eMolyneux E, Weber MW. Applying the right standards to improve hospital performance in Africa. \u003cem\u003eLancet (London, England)\u003c/em\u003e 2004;364(9445):1560-1. doi: 10.1016/s0140-6736(04)17326-1 [published Online First: 2004/11/03]\u003c/li\u003e\n\u003cli\u003eChinese Diabetes Society. Chinese Guidelines for the Prevention and Treatment of Type 2 Diabetes (2020 edition) [in Chinese]. \u003cem\u003eChinese Journal of Diabetes\u003c/em\u003e 2021;13(4):315–409.\u003c/li\u003e\n\u003cli\u003eShen M, Chen D, Zhao R, et al. Real-world adherence to toxicity management guidelines for immune checkpoint inhibitor-induced diabetes mellitus. \u003cem\u003eFrontiers in endocrinology\u003c/em\u003e 2023;14:1213225. doi: 10.3389/fendo.2023.1213225 [published Online First: 2023/08/09]\u003c/li\u003e\n\u003cli\u003eWang X, Luo JF, Qi L, et al. Adherence to self-monitoring of blood glucose in Chinese patients with type 2 diabetes: current status and influential factors based on electronic questionnaires. \u003cem\u003ePatient preference and adherence\u003c/em\u003e 2019;13:1269-82. doi: 10.2147/ppa.S211668 [published Online First: 2019/08/16]\u003c/li\u003e\n\u003cli\u003eHiguchi KS, Davies BL, Edwards N, et al. Implementation of clinical guidelines for adults with asthma and diabetes: a three-year follow-up evaluation of nursing care. \u003cem\u003eJ Clin Nurs\u003c/em\u003e 2011;20(9–10):1329-38. doi: 10.1111/j.1365-2702.2010.03590.x [published Online First: 2011/04/16]\u003c/li\u003e\n\u003cli\u003eLian J, Liang Y. Diabetes management in the real world and the impact of adherence to guideline recommendations. \u003cem\u003eCurr Med Res Opin\u003c/em\u003e 2014;30(11):2233-40. doi: 10.1185/03007995.2014.952716 [published Online First: 2014/08/12]\u003c/li\u003e\n\u003cli\u003eJameson K, D'Oca K, Leigh P, et al. Adherence to NICE guidance on glucagon-like peptide-1 receptor agonists among patients with type 2 diabetes mellitus: an evaluation using the Clinical Practice Research Datalink. \u003cem\u003eCurr Med Res Opin\u003c/em\u003e 2016;1(1):49–60.\u003c/li\u003e\n\u003cli\u003eZou K, Yang N, He S, et al. Development of a generalised tool for evaluating success of clinical practice guidelines implementation (A-GIST). \u003cem\u003eBMJ Evid Based Med\u003c/em\u003e 2025 doi: 10.1136/bmjebm-2024-113308 [published Online First: 2025/04/18]\u003c/li\u003e\n\u003cli\u003eYang N, Zou K, He S, et al. Reliability and validity analysis of Guideline Implementation Success Assessment Tool (A-GIST) [in Chinese]. \u003cem\u003eChinese Journal of Evidence-Based Medicine\u003c/em\u003e 2024;24(8):904-09.\u003c/li\u003e\n\u003cli\u003eZeng L, Li Y, Zhang L, et al. Guideline use behaviours and needs of primary care practitioners in China: a cross-sectional survey. \u003cem\u003eBMJ Open\u003c/em\u003e 2017;7(9):e015379. doi: 10.1136/bmjopen-2016-015379 [published Online First: 2017/09/06]\u003c/li\u003e\n\u003cli\u003eJin YH, Tan LM, Khan KS, et al. Determinants of successful guideline implementation: a national cross-sectional survey. \u003cem\u003eBMC Med Inform Decis Mak\u003c/em\u003e 2021;21(1):19. doi: 10.1186/s12911-020-01382-w [published Online First: 2021/01/16]\u003c/li\u003e\n\u003cli\u003eWang T, Tan JB, Liu XL, et al. Barriers and enablers to implementing clinical practice guidelines in primary care: an overview of systematic reviews. \u003cem\u003eBMJ Open\u003c/em\u003e 2023;13(1):e062158. doi: 10.1136/bmjopen-2022-062158 [published Online First: 2023/01/08]\u003c/li\u003e\n\u003cli\u003eCorrea VC, Lugo-Agudelo LH, Aguirre-Acevedo DC, et al. Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. \u003cem\u003eHealth Res Policy Syst\u003c/em\u003e 2020;18(1):74. doi: 10.1186/s12961-020-00588-8 [published Online First: 2020/07/01]\u003c/li\u003e\n\u003cli\u003eZhou P, Chen L, Wu Z, et al. The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature. \u003cem\u003eJ Clin Epidemiol\u003c/em\u003e 2023;162:169 − 81. doi: 10.1016/j.jclinepi.2023.08.017 [published Online First: 2023/09/02]\u003c/li\u003e\n\u003cli\u003eTian C, Xu M, Wang Y, et al. Barriers and strategies of clinical practice guideline implementation in China: aggregated analysis of 16 cross-sectional surveys. \u003cem\u003eJournal of Public Health\u003c/em\u003e 2024;32(10):1891 − 904. doi: 10.1007/s10389-023-01949-7\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7159169/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7159169/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eType 2 diabetes mellitus (T2DM) is the leading cause of morbidity and mortality in China. The 2020 Chinese clinical practice guideline for prevention and treatment of T2DM was published at April 2021, yet its status of implementation is unclear.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo investigate the success of implementation of the 2020 Chinese clinical practice guideline of prevention and treatment of T2DM in public hospitals in China and to identify its associated factors and barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted using the data collected from surveillance data from the National Hospital Management and Service Guide Centre of National Health Commission of China. The status of implementation was evaluated using the Guideline Implementation Success Assessment Tool (A-GIST). Descriptive analysis was conducted to explore the status and distribution of guideline implementation among regions, provinces and hospitals, and barriers of implementation. ANOVA test and logistic regression analysis were used to analyze the factors associated with guideline implementation. Significant level was set as 0.05. All statistical analyses were conducted using Stata SE 15.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total, 705 participants (365 health professionals and 340 patients) from 26 hospitals and 13 provinces were included. The total implementation score was 76.86 (30.25), ranging from 65.30 to 97.94 among provinces and 42.95 to 97.94 among hospitals. Univariate analysis found that east and west region, senior age, higher degree, physician or pharmacist, senior title, and tertiary hospital had higher total implementation score than their counterparts (p \u0026lt; 0.05). Multivariate regression analysis found middle region (β =-15.71, 95%CI: -24.32, -7.11) and nurse professionals (-16.30, -24.14, -8.45) were independently associated with lower total implementation score. Hospital/department organized learning (69.01%), literature database (53.20%), and academic conference (47.50%) were top 3 routines to access guideline. 43(11.8%) health professionals reported barriers of guideline implementation, among which influence on patient treatment choices (5.2%), impact of medical insurance (6.3%), awareness and familiarity with the guidelines (4.1%), patients’ compliance (8.2%) were top barriers in aspects of guideline-itself, environment, health professional and patient factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe success of implementation of the type 2 diabetes guideline was fair in hospitals in China. There was substantial difference among regions, hospitals, and health professional groups, which warranted improvement. A-GIST is a useful tool for examining the landscape of success of implementation of CPCs and informing the targets and strategies of guideline implementation interventions.\u003c/p\u003e","manuscriptTitle":"Accessing the success of implementation of the 2020 Chinese clinical practice guideline for prevention and treatment of type 2 diabetes mellitus in hospitals: a cross-sectional study using A-GIST","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 10:12:15","doi":"10.21203/rs.3.rs-7159169/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2026-03-20T18:08:27+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-08-28T01:13:18+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T21:51:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-23T01:42:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2025-07-22T08:47:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2cfd34a4-9c59-4736-89cb-5002d6160f7b","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-20T22:08:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 10:12:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7159169","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7159169","identity":"rs-7159169","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}