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The authors are to be highly commended for undertaking this important work. As a former AHRQ EvidenceNOW Principal Investigator, the findings are consistent with the experiences of our team. Three observations about this work. First, these findings also have implications for those planning to conduct embedded pragmatic clinical trials. It may be difficult to recruit health care settings for these trials for many of the same reasons articulated in this study. Second, in addition to participation, among those who make an initial commitment, many may find that they cannot follow through with participating in the project for many of the same reasons: lack of time, staff turnover, etc. resulting in significant attrition. Finally, interpreting quality improvement study findings is difficult in light of both this attrition, not to mention the inability of the primary care clinic to reliably implement the improvement changes supported by the study protocol due to these same factors. One approach might be to develop better measures of "quality improvement capacity" within the participating clinics, one that is sensitive to change over time and that might be used as a covariate or mediator in analyzing results and interpreting findings.