Implementing a prediabetes clinical decision support system in a large primary care system: Design, methods, and pre-implementation results.

BACKGROUND: Early detection of prediabetes and management of cardiovascular (CV) risk factors to prevent CV disease is essential, but clinicians are often slow to address this risk. Clinical decision support (CDS) systems, with appropriate implementation, can potentially improve prediabetes identification and treatment. METHODS/DESIGN: 34 Midwestern primary care clinics were randomized to receive or not receive access to a prediabetes (PreD) CDS tool. Between October 2016 and December 2019, primary care clinicians (PCPs) received Pre-D CDS alerts during visits with adult patients identified with prediabetes and who met minimal inclusion criteria and had at least one CV risk factor not at goal. The PCP Pre-D CDS included a summary of six modifiable CV risk factors and patient-specific treatment recommendations. Study outcomes included total modifiable CV risk, six modifiable CV risk factors, use of CV medications, and referrals. The Consolidated Framework for Implementation Research was used to examine CDS implementation processes. DISCUSSION: This cluster-randomized pragmatic trial allowed PCPs the opportunity to improve CV risk in a timely manner for patients with prediabetes. Effectiveness will be assessed using an intent-to-treat analysis. Implementation processes and outcomes will be assessed through interviews, surveys, and electronic health record data harvested by the CDS tool itself. Pre-implementation interviews and activities identified key strategies to incorporate as part of the Pre-D CDS implementation process to ensure acceptability and high use rates. Analyses are ongoing and trial results are expected in mid-2021.

Taper-Trunnion Interface Stress Varies Significantly With Head Size and Activity.

BACKGROUND: Total hip arthroplasty is performed with modular parts. Either a metal or ceramic ball is fastened to the trunnion of a femoral stem via a Morse taper. This implant scenario has been successful. However, recently larger (36 mm or greater) metal heads have become more popular as a means to reduce the incidence of hip joint dislocation. Today, a number of clinical failures have occurred due to mechanically assisted crevice corrosion at the head (taper) stem (trunnion) interface necessitating revision surgery. The objective of this research is to investigate how trunnion stress varies with head size, and how taper-trunnion geometric parameters including horizontal lever arm (HLA), taper engagement level, and a new parameter called trunnion load offset affect trunnion stresses. We hypothesized that trunnion stress may increase with increasing head size and HLA. METHODS: This hypothesis was tested by conducting finite element analysis of a titanium hip stem and 4 commercially available cobalt-chromium femoral heads subjected to 4 different moderate to severe physiological loading conditions. RESULTS: Results showed that trunnion stress increases with increasing head size, increased HLA, and trunnion load offset. It was also found that under certain load cases the trunnion stresses get exceptionally high, especially for the larger head sizes. CONCLUSION: This study suggests trying to avoid larger femoral head sizes that may result in higher implant stresses under certain loading conditions.