Table 1 Ten key ingredients for implementation research proposals (modified from Proctor EK et al.[1])

Evidence of a gap in quality

In addition to support from the literature, research team members were able to cite their own work about potential overtreatment of diabetes. Another gap is in knowledge about how to de-implement well-established practices.

Evidence-based treatment to be implemented

Discontinuing treatment that is of little benefit, but potentially harmful is valid on its face.

Conceptual model and theoretical justification

Both the original application and the revision modified an established conceptual model. However, in response to the reviews, the aspects of the model related to ‘unlearning’ were eliminated.

Stakeholder priorities, engagement in change

This project involved assessment of a natural experiment. The priorities were set by central administration. However, it occurred in the context of similar initiatives in the private sector.

Setting’s readiness to adopt new services/ treatments/programs

Preliminary data provided some support for the readiness of the settings, but variation is expected and is the focus of the proposal.

Implementation strategy/process

As a natural experiment, implementation strategy and process were outside the control of the research team.

Team experience with the setting, treatment, implementation process

The team members have had a long track record of working together in the general area of diabetes care delivery. They have special expertise in implementation research as well as operational implementation.

Feasibility of proposed research design and methods

Feasibility was a major factor in designing a multi-level (national and local facility) study based on different kinds of data.

Measurement and analysis section

This section was one of the largest in the application.

Policy/funding environment; leverage or support for sustaining change

It is clear that this topic of potential overtreatment of diabetes has gained considerable traction: In addition to the Choosing Wisely initiative itself, professional societies have adopted the concept of individualization of A1c targets and modified their practice guidelines accordingly.