Integrating Research and Practice to Bridge the Researcher/Practitioner Divide: Three Examples

involving Diabetes Shared Medical Appointments – 3/24/09

Susan R. Kirsh, MD and David C. Aron, MD, MS

Louis Stokes Cleveland DVAMC 14(W), 10701 East Blvd., Cleveland, OH 441061

Case Western Reserve University School of Medicine, Cleveland, OH

with Special Thanks to Wen-Chih Wu, MD, and Tracey H. Taveira, PharmD

(Providence VAMC) and David Edelman, MD (Durham VAMC)

Quality Enhancement

Research Initiative

CIPRS Background and Mission QUERI and HSR&D contributions to improved performance

and quality of care in the VA have been considerable over past 10 years, but significant challenges remain

CIPRS was established to support and strengthen:

– VA implementation research (Goal 1)

– VA implementation policy and practice (Goal 2)

– and to support QUERI program and leadership (Goal 3)

Disclaimer

The opinions expressed in the following presentation are solely those of the presenters, and do not represent those of any agency or organization

Diogenes: “Of what use is being a philosopher if you don’t annoy anyone?

The Researcher-Practitioner Divide

• Research-practice gap• Science-practice gap• Knowledge-practice gap • Academic-Management

gap

Many suppliers and users of social research are dissatisfied, the former because they are not listened to, the latter because they do not hear much they want to listen to (Lindblom & Cohen, 1979).

How the research-practice gap is usually depicted: a knowledge transfer (translation) gap.

Publication

Bibliographic databases

Submission

Reviews, guidelines, textbook

Negative results

variable

0.3 year

6. 0 - 13.0 years50%

46%

18%

35%

0.6 year

0.5 year

9.3 years

It takes 17 years to turn 14 per cent of original researchIt takes 17 years to turn 14 per cent of original research to the benefit of patient careto the benefit of patient care

Dickersin, 1987

Koren, 1989

Balas, 1995

Poynard, 1985

Kumar, 1992

Kumar, 1992

Poyer, 1982

Antman, 1992

Negative results

Lack of numbers

Expertopinion

Inconsistentindexing

17:14

Original research

Acceptance

Implementation

R

The Pipeline Fallacy of Producing & VettingResearch to Get Evidence-Based Practice*

Peer ReviewOf Grants

PublicationPriorities &Peer Review

ResearchSynthesis

Guidelines forEvidence-BasedPractice

Academic appointments,promotion, & tenure criteria

Funding; patientneeds, demands; local practicecircumstances;professionaldiscretion; credibility & fit ofthe evidence.

-

Evidence-basedMedicine movement

Practice

Priorities for Research Funding

*Based on Green, L.W. From research to “best practices” in other settings and populations. Am J Health Behavior 25:165-178, April-May 2001. Full text: www.ajhb.org/25-3.htm

The 17-year odyssey

Blame the practitioneror blame dissemination

This is Not a New Problem: The Case of Scurvy• 1593 - Sir Richard

Hawkins recommended the following treatment for scurvy: "That which I have seen most fruitfull for this sicknesse, is sower [sour] oranges and lemmons."

• 1601- Lancaster shows that lemon juice supplement eliminates scurvy among sailors (non-randomized controlled trial)

This is Not a New Problem: The Case of Scurvy

• 1747- Lind shows that citrus juice supplement eliminates scurvy

• 1795- (194 years after Level 2 evidence) British Navy implements citrus juice supplement

NIH Roadmap InitiativeNIH Roadmap Initiative--translating discoveries into health*--translating discoveries into health*

*Zerhouni E. Science 2003, Oct 3;302(5642):63-72 .

The roadmap lesstraveled?**

“The Roadmap identifies the most compelling opportunities in three arenas: new pathways to discovery, research teams of the future, and reengineering the clinical research enterprise” (Zerhouni, p. 63).*

**Green LW. Am J Prev Med., 2007; 33(2):137-38, after K. Grumbach.

*Westfall, J. M. et al. JAMA 2007;297:403-406.

"Blue Highways" on the NIH Roadmap*

ProgramEvaluation,CQI, PolicyAnalysis, TA in EBPadaptation. Systems research.

Lawrence W. Green, UCSFLawrence W. Green, UCSF

3 Conceptualizations of the Gap 3 Conceptualizations of the Gap Between Research & PracticeBetween Research & Practice

• Knowledge Transfer GapKnowledge Transfer Gap: Practitioners need to : Practitioners need to receive the lessons of research and put them into receive the lessons of research and put them into practice. practice.

• Research and practice are entirely separate Research and practice are entirely separate disciplinesdisciplines and each must develop their own and each must develop their own answers to their own problemsanswers to their own problems

• Knowledge Production GapKnowledge Production Gap - Research and - Research and practice have complementary perspectives and practice have complementary perspectives and skills that need to be used together to address the skills that need to be used together to address the real need, collaborative knowledge production. real need, collaborative knowledge production.

Van De Ven A, Johnson P. Knowledge for theory and practice. Academy of Management Review. 2006;31(4).

Practice Research

Notions of evidence

Colloquial (Contextual)

Anything that seems reasonable p<0.5?

Practice relevant

Scientific’ (Context free)

Proven empirically-rigorously p<0.05?

Theoretically driven

Time frames for results

Timely As long as it takes

Languages for communication

Clear Message

Practitioner jargon

Caveats and qualifications

Research jargon

Work environment

Focus on service deliveryInfluenced by the need to respond to the immediate reality of human need

Focus on strict adherence to research rules that give objective validity to results and publication of research findingsInfluenced by academic achievement, international research reputation, sources of funding

• Based on Davies et al. (2000b); Pyra (2003); Shonkoff (2000).

Differing World Views

Research

Project is fixed Context

must adapt

Context is fixed

Project must adapt

PracticeT. Greenhalgh

• Rigor vs. relevance

• Internal vs. external validity

• Isolation of a phenomenon from context (so that it can be more rigorously studied) when context matters

• Our methods, theories, world view don’t match the problems or apparent solutions

Differing World Views

Precise and pointless.

Rigor vs Relevance

The two kinds of research?

• Quantitative / positivist / deductive– Hard and spiky

• Qualitative / phenomenological / social constructivist / interpretivist / etc – Soft and cuddly

Often suggested that researchers need to choose one or the other.

Michael Wood http://userweb.port.ac.uk/~woodm/

Which side are you on?

• To hard and spiky people, soft and cuddly research is lacking in rigour

• To soft and cuddly people, hard and spiky research is superficial and lacking in richness and relevance

… but is this a genuine dichotomy?

Michael Wood http://userweb.port.ac.uk/~woodm/rm/

‘As the complexity of a system increases our ability to make a precise and yet significant statement about its behaviour diminishes until a threshold is reached beyond which precision and significance (or relevance) become almost mutually exclusive characteristics.’

(Zadeh, 1965)

Two Models of Rigor vs Relevance

Relevance to practice

Importance of rigor and relevance

Populist

Rig

our

of m

etho

d

Pedantic

Populist: insufficient rigour/incorrect, ill conceived/conducted studies, populist books, inadequate refereeing

Puerile

Puerile: low practical relevance, insufficient rigour/ incorrect, ill conceived/ conducted studies

Pedantic: fastidious design and sophisticated analysis but relevance limited (myopic)

Pragmatic

Pragmatic: rigor in method and relevant to organisations

Modified from MNK Saunders, Oxford Brooks Univ.Developed from: Anderson et al. (2001)

Two separate disciplines?

• views knowledge of theory and practice as distinct kinds of knowledge (not necessarily in opposition to each other; complementary). – Each reflects a different ontology (truth claim) – Each reflects a different epistemology

(method) for addressing different questions.

• Sophia and phronesis

Phronesis• Aristotle distinguishes between two intellectual virtues:

sophia and phronesis. Sophia (usually translated "wisdom") is the ability to think well about the nature of the world, and is used in our attempts to discover why the world is the way it is (this is sometimes equated with science); sophia involves deliberation concerning universal truths

• Phronesis is the ability to think about how and why we should act in order to change things, and especially to change our lives for the better

• Phronesis is about practical wisdom/judgement routed in experience

René Kemp

• Phronesis is concerned with particulars, because it is concerned with how to act in particular situations. One can learn the principles of action, but applying them in the real world, in situations which one could not have foreseen, requires experience of the world

• The importance of phronesis to contemporary thought has been spelled out by Bent Flyvbjerg in his book Making Social Science Matter: Why Social Inquiry Fails and How it Can Succeed Again; Flyvbjerg argues that instead of trying to emulate the natural sciences, social science should be practiced as phronesis.

René Kemp

Viewing the gap as…a knowledge production problem

If the duty of the intellectual in society is to make a difference, the [academic] research community has a long way to go to realize its potential. The action steps to resolve the old dichotomy of theory and practice were often portrayed with the minimalist request for researchers to engage with practitioners through more accessible dissemination. But dissemination is too late if the wrong questions have been asked. A wider and deeper form of engagement between researchers and practitioners would entail experimentation with the co-funding, co-production, and co-dissemination of knowledge. Andrew Pettigrew,

“Management Research After Modernism,” Brit. J Mgmt, 2001, vol. 12, iss. SPI/1, pp. S61-S70

• We contend that:– researchers and practitioners must inform one

another in order to optimize both research and care delivery.

– links between research and practice can occur at various points in the process, allowing clinical managers and researchers to become better aligned to develop new and potentially generalizable knowledge having significant impact on the improvement of healthcare.

– Understanding how best to facilitate linkages and collaboration, can expedite translation of research knowledge into practice and allow more evidence based improvements to be implemented into practice as well as influence research agendas.

• We describe three brief case studies in which attempts were made with varying success to bridge the researcher-practitioner gap. These three examples, all involving Shared Medical Appointments (SMAs) for diabetes will illustrate both fixed and evolving interventions and the degree to which research and clinical operations interfaced.

• Personnel

• staff-: 1 MD (general internist), 1NP/CDE, 1 RN, 1 Pharm D, 1 Psychologist (multi-disciplinary team)

• 10-20 patients/session Sessions

• 90 minutes length; Return visit interval: 4-8 weeks until goals achieved

• Group activities

• Education; Review of labs; Discussion

•Individual activities•Medication management•Referrals•Individualized plan of care outline

First, what is an SMA?

http://www.queri.research.va.gov/tools/diabetes/shared-med-appt.pdf

Case 1. Based upon a research need related to the evidence both published and unpublished, an intervention was designed and implemented. Following

implementation, there was minimal alteration of the intervention.

Research Need

Intervention

Ou

tco

me

s

Evidence-Based

Practice

Implementation Process & Its

Context

Barriers & Facilitators

Intervention Design

P

DS

A

1

Data/Information From Collaborator

The linear logical model…

Identify the problem

Commission research

Analyse the results

Choose the best option

Establish the policy

Implement the policy

Evaluation

Case 2. Intervention Dose Adjustments. Based upon a clinical need, an intervention was designed and implemented. Following implementation

the intervention remained fixed, although the dose varied.

Clinical Need

P

DS

A P

DS

A P

DS

A P

DS

A P

DS

A

P

DS

A P

DS

A P

DS

A P

DS

A P

DS

A

Intervention Design

Intervention

Ou

tco

me

s

Evidence-Based

Practice

P

DS

A

InterventionDose Adjustment

Implementation Process & Its Context

Barriers & Facilitators

2

1

1

Dose Adjustments

A P

S D

APS

D

A P

S DD S

P ADATA

*** Danger *** The journey up the ramp of complexity is NOT linear.

Com

ple

xit

y

Time

Com

plex

ity

Time

APS

D

P PS D

A P

S DP

SD

AP

SD

Challenges

Opportunities

P

D

AS

PD

Tomolo, Lawrence, and AronLegend:P=Plan D= Do = Barrier = Direct flow of impact S=Study A=Act = Lingering background impact Arrowhead = Feedback or feedforwardDifferent Sizes of letters and cycles and bolding of letters = denotes differences in importance/impact

Case 3. Action research. Based on a clinical need and review of evidence both published and unpublished, an intervention was designed and implemented.

The implementation process involved multiple plan do study act cycles. These cycles included redesigns of the intervention.

Clinical Need

P

DS

A P

DS

A P

DS

A P

DS

A P

DS

A

P

DS

A P

DS

A P

DS

A P

DS

A P

DS

A

Intervention Design

Intervention

Ou

tco

me

s

Evidence-Based

Practice

P

DS

A

1P

DS

AP

DS

A

P

DS

AP

DS

A

P

DS

A

Intervention

Redesign

2

3

4

5

6

Implementation Process & Its Context

P

DS

A

1 P

DS

A

2

2

1

Barriers and facilitators

Continuum of Quality Improvement and Research:

Rigor vs. Relevance

Operations

“Relevant”Context-Dependent

Problem SolvingQuantitative >, <, or =

QualitativePre-test post-test or

Quasi-experimental designsTends to be NON-LINEAR

Research

“Rigorous” Identify generalizable

knowledge, i.e.,Eliminate Context

PublishableQuantitative>Qualitative

RCTs RuleTends to be LINEAR

• Continuum not a dichotomy• Goal is relevance moving as close to rigor as one can

Potential

Synergy

• Initial design: pre-test post-test with 44 patients• Reviewer comments - 3 times

– Lack of recognition that this was a quality improvement project

• Put ‘QI’ in the title

– Organization/Format issues• Inserted SQUIRE as signposts and follow a familiar format

Reviewer #2 comments re: first version

• “The major problem is the lack of a control group. The participants were selected based on high levels of particular measures.”

• “The second problem is that the people are treated in clusters, and that therefore the independence assumption of the statistical tests is violated”

• “An appropriate method of analysis should be used– such as multilevel models, generalised estimating equations or Huber-White sandwich estimators.”– (Note that subsequent reviews from this reviewer

were even worse!

Response–Changed design to quasi-

experimental: Added a control group – matched, concurrent, but not randomized. • Use as much rigor as possible: Consider

sources of bias and address wherever possible eg., regression to the mean

– Required 3 revisions overall• Persistence pays off• It was a much better paper as a result of the

reviewers’ comments. Leave your ego out of it.

• Qualitative work adds another dimension that makes quantitative data more meaningful

• Used framework of Grol model to add structure and rigor

• Triangulation

Models of Researcher-Practitioner Collaboration

• Separate and not even talking (~unidisciplinary)

• Separate, but at least talking (~multi-disciplinary)

• Co-creation of knowledge (~interdisciplinary and maybe even transdisciplinary)– Action Research

– Engaged Scholarship

– Mode 2 Knowledge Generation

On the Impossibility of Collaborative Research – and on the Usefulness of Researchers and Practitioners Irritating each Other.

A. Kieser and L. Leizer

Paper submitted to Special Issue on “Organization Studies as Applied Science: The Generation and Use of Academic Knowledge about Organizationa,” Guest Eds. P. Jarzabowski, S. Mohrman, and A.G. Scherer.

Action Research

• a form of systematic inquiry intended to produce both change (action) and understanding (research)

• it involves ‘stakeholders’ in the research in both shaping and carrying out the research.

*Green, George, Daniel, et al., Participatory Research…Ottawa: Royal Society of Canada, 1997. www.lgreen.net/guidelines.html

Linking Research & OperationsKnowledge Generation

• Mode 1– Linear and often unidisciplinary– Developed separate from context– Application takes place late in the process

of generating knowledge

• Mode 2– Iterative, non-linear, and

interdisciplinary– Developed in context– Application is incorporated early– Includes a range of stakeholders– Involves alliances among

different knowledge communities

Applied Research

Development

Basic Research

Technology

Application

Reference: Gibbons, Michael; Camille Limoges, Helga Nowotny, Simon Schwartzman, Peter Scott, & Martin Trow (1994). The new production of knowledge: the dynamics of science and research in contemporary societies. London: Sage.

Engaged Scholarship (A. Van de Ven)

• A collaborative form of inquiry where investigators leverage their different perspectives to learn about a complex problem in reality. “Intellectual Arbitrage”

• A view of how scholars define their relationships with their communities

– Other academics, practitioners, students

• A relationship involving negotiation, mutual respect, and collaboration to produce a learning community.

• Studying complex problems with (not for) practitioners and other stakeholders

Major Activities in an Engaged Scholarship Study

TheorySolution

Model

Reality

Proble

m F

orm

ulatio

n

Theory BuildingRes

earc

h Des

ignProblem

Solving Problem FormulationSituate, ground, diagnose & infer the problem up close and from afar

Involve those who experience& know the problem

Theory BuildingCreate, elaborate & justify a theoryby abduction, deduction & induction

Involve knowledge experts in relevant disciplines & functions

Research DesignDevelop variance or processmodel to study theory

Involve methods experts & peopleproviding access & information

Problem SolvingCommunicate, interpret & negotiatefindings with intended audience.

Involve intended audienceto interpret meanings & uses

Iterate& Fit

Study Context: Complexity, research team organization, stakeholders’ perspectives

A. Van de Ven

Potential Benefits of Participatory ResearchPotential Benefits of Participatory Research

• Results are relevant to interests, circumstances, and Results are relevant to interests, circumstances, and needs of those who would apply themneeds of those who would apply them

• Results are more immediately actionable in local situations Results are more immediately actionable in local situations for people and/or practitionersfor people and/or practitioners

• Generalizable findings more credible to people, Generalizable findings more credible to people, practitioners and policy makers elsewhere because they practitioners and policy makers elsewhere because they were generated in partnership with people like themselveswere generated in partnership with people like themselves

• Helps to reframe issues from health behavior of Helps to reframe issues from health behavior of individuals to encompass system and structural issues.individuals to encompass system and structural issues.

Green LW, Mercer SL. Am J Public Health Dec. 2001.

Differences Between Inside & Outside Inquiry-A philosophical digression

Roger Evered & Meryl Reis Louis, Alternative perspectives in the organizational sciences: “Inquiry from the inside” and “inquiry from the outside,” Academy of Management Review, 6, 3 (1981), p. 389.

Is Action Research Scientific?

• No, when judged by positivist science

• It doesn’t meet the “covering law” criterion– Actions derive meaning from the end pursued,

not prior associations– Planned interventions and social systems

cause variables to be dependent on context– Actions are seldom discrete events

Sussman

Is Action Research Scientific?• Yes, given different philosophical viewpoints

– Praxis: the art of acting upon the conditions one faces in order to change them

– Hermeneutics: the interpretation of languages, culture, and history (no knowledge is possible without presupposition)

– Existentialism: asserts the importance of human choice and values, with respect to action, avoids causal explanations

– Pragmatism: shifted the criterion of truth to the practical consequences for adopting a particular stmt.

– Process philosophies: you cannot step into the same social system twice, organizations constantly change, they are different

– Phenomenology: insists on the primacy of immediate subjective experience is the basis for knowledge

• It generates knowledge which is contingent on a particular situation and which develops the capacity of members of an organization to solve their own problems

Sussman

Engaged Scholarship is based ona Critical Realist Philosophy of

Science• There is a real world out there, but our understanding of it is

limited

• All facts, observations & data are theory laden

• Social science has no absolute, universal, error-free truths or laws

• No form of inquiry can be value free & impartial; each is value full

• Knowing a complex reality demands use of multiple perspectives

• Robust knowledge is invariant (in common) across multiple models

• Models that better fit the problems they are intended to solve are selected, producing an evolutionary growth of knowledge.

Van de Ven

Minimizing Potential PitfallsAvoiding false negatives and false positives:

– Systematic search for disconfirming evidence– Distinguish between theory failure and implementation

failure– Understanding context: implementation environment,

participant characteristics and other interventionsSome approaches:

– Addressing through design – eg experimental and quasi-experimental designs

– Addressing through data collection – eg Beneficiary Assessment

– Addressing through iterative analysis and collection – eg Mixed methods, Contribution Analysis, Multiple Levels and Lines of Evidence (MLLE), List of Possible Causes (LOPC) and General Elimination Methodology (GEM)

P. Rogers, Royal Melbourne Institute of Technology. www.prgaprogram.org/riw/files/papers/Rogers%20material%20for%20workshop.ppt.

Two key checks• Use of a devil’s advocate or critical friend.

Remember the problem of confirmation bias – you are likely to be more enthusiastic about evidence that confirms your pet ideas than about evidence that undermines it! Get someone to try and be critical and find difficulties with your research – then fix or (if unfixable) discuss the problems.

• Triangulation – compare results from different sources. Applies to data, methods, observers, theories (Robson, 2002: 174).

Michael Wood http://userweb.port.ac.uk/~woodm/rm/rm.ppt

Strategic EDUCATIONAL

Supports

Bridging Research and Practice

Improved Impact

Improved Understanding

CurrentPractices

Existing Understanding

Strategic POLICY Supports

User-Inspired Research

Research-Inspired Reflection

Dale A. Blyth, Ph.D., U. Minn.

The Bridge (not the Pipeline) from Research The Bridge (not the Pipeline) from Research to Practice and Backto Practice and Back

• If we want more evidence-based practice, we If we want more evidence-based practice, we need more practice-based evidence. need more practice-based evidence.

• The importance of practitioners and policy-The importance of practitioners and policy-makers in shaping the research questions.makers in shaping the research questions.

• Practitioners and their organizations Practitioners and their organizations represent the structural links (and barriers) represent the structural links (and barriers) to addressing the important determinants of to addressing the important determinants of health behavior at each level. Engage them, health behavior at each level. Engage them, not at passive recipients, but as partners…not at passive recipients, but as partners…

*Green, L.W. From research to “best practices” in other settings and populations. Am J Health Behavior 25:165-178, April-May 2001. Full text: www.ajhb.org/25-3.htm.

Strategies for building relationships between the three cultures (researchers, practitioners, and

policy makers):• Ongoing, regular communication between researchers and users:

(eg, conduct spontaneous and planned exchanges and face to face meetings, partnerships, best practice demonstrations, workshops and seminars)

• Involve practitioners and decision makers early and throughout all stages of the research process

• Generate knowledge in a shared manner• Allow sufficient time for people to understand fully and connect their

needs to what is being proposed/discussed• Utilise opportunities for researchers to ‘shadow’ policymakers and

vice versa• Include decision makers in the governing or consulting bodies of

research centres

• Sources: Black & Donald (2001); Davies et al. (2000b); Fixsen et al. (2005); Innvaer et al. (2002); Lomas (2000); Nutbeam (2003); Percy-Smith et al. (2002); Pyra (2003). KERRY LEWIG, FIONA

ARNEY AND DOROTHY SCOTT

Summary• The cases illustrate that there are opportunities for alignment

and linkage between research and operations (practitioners and managers) despite their distinct cultures, differing world views, and unique terminology.– Each mode of knowledge generation has its own

problems. (the rigor vs relevance issue)• There are various points along the research and operation

paths of knowledge generation and translation where the goals and objectives of the researcher and manager can be aligned. – It is at these points of alignment where each can optimally

inform the other.

Reference List1. Greiner AC, Knebel E. Health professions education: A bridge to quality - Institute of Medicine. Washington:

National Academies Press; 2003.2. Lewig K, Arney F, Scott D. Closing the research-policy and research-practice gaps: Ideas for child and family

services. Family Matters 2006; 74:12-19.3. Chaffin M, Friedrich B. Evidence-based treatments in child abuse and neglect. Children and Youth Services

Review 2004; 26:1097-1113.4. Benbasat I, Zmud RW. Empirical research in information systems: the practice of relevance. MIS Quarterly

1999; 23(1).5. Mason RO. MIS Experiments: a pragmatic perspective. In: Benbasat I, editor. The Information Systems

Research Challenge: Experimental Research Methods. Cambridge, MA: Harvard Buiness School; 1989.6. Davenport TH, Markus ML. Rigor vs. relevance revisited: response to Benbasat and Zmud. MIS Quarterly

1999; 23(1).7. Robey D, Markus ML. Beyond rigor and relevance: producing consumable research about information

systems. Information Resources Management Journal 1998; 11.8. Keen PGW. Relevance and rigor in information systems research: improving quality, confidence, cohesion

and impact. In: Nissen HE, Heinz KL, Hirschleim R, editors. Information Systems Research: Contemporary Approaches and Emergent Traditions. North Holland; 1991.

9. Gibbons M, Limoges C, Nowotny H, Schwartzman S, Scott P, Trow M. The New Production of Knowledge: The Dynamics of Science and Research inContemporary Societies. London.: Sage; 1994.

10. Reason P, Bradbury H. Handbook of Action Research. London: Sage; 2006.11. Van de Ven A. Engaged Scholarship: A Guide for Organizational and Social Rsearch. Oxford University

Press, 200712. Jaber R, Braksmajer A, Trilling J. Group Visits: A Qualitative Review of Current Research. Journal of

American Board of Family Medicine 2006; 19:276-290.13. Kirsh SR, Watts S, Pascuzzi K et al. Shared medical appointments based on the chronic care model: a

quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Quality Safety in Health Care 2007; 16:349-353.

14. Kirsh S, Lawrence R, Aron D. Tailoring an Intervention to the Context and System Redesign Related to the Intervention: Case Study of Implementing Shared Medical Appointments for Diabetes. Implementation Science 2008; 3:34.