A qualitative framework-based evaluation of radiology clinical decision support initiatives: eliciting key factors to physician adoption in implementation.

OBJECTIVES: To illustrate key contextual factors that may have effects on clinical decision support (CDS) adoption and, ultimately, success. MATERIALS AND METHODS: We conducted a qualitative evaluation of 2 similar radiology CDS innovations for near-term endpoints affecting adoption and present the findings using an evaluation framework. We identified key contextual factors between these 2 innovations and determined important adoption differences between them. RESULTS: Degree of electronic health record integration, approach to education and training, key drivers of adoption, and tailoring of the CDS to the clinical context were handled differently between the 2 innovations, contributing to variation in their relative degrees of adoption and use. Attention to these factors had impacts on both near and later-term measures of success (eg, patient outcomes). DISCUSSION: CDS adoption is a well-studied early-term measure of CDS success that directly impacts outcomes. Adoption requires attention throughout the design phases of an intervention especially to key factors directly affecting it, including how implementation across multiple sites and systems complicates adoption, which prior experience with CDS matters, and that practice guidelines invariably require tailoring to the clinical context. CONCLUSION: With better planning for the capture of early-term measures of successful CDS implementation, especially adoption, critical adjustments may be made to ensure that the CDS is effectively implemented to be successful.

Efficacy of Articaine versus Lidocaine in Supplemental Infiltration for Mandibular First versus Second Molars with Irreversible Pulpitis: A Prospective, Randomized, Double-blind Clinical Trial.

INTRODUCTION: Profound pulpal anesthesia is difficult to achieve in mandibular molars with irreversible pulpitis (IP). However, there are no published randomized controlled clinical trials comparing the success of supplemental buccal infiltration (BI) in mandibular first versus second molars with IP. The purpose of this prospective, randomized, double-blind study was to compare the efficacy of 4% articaine with 2% lidocaine for supplemental BIs in mandibular first versus second molars with IP after a failed inferior alveolar nerve block (IANB). This study's sample was combined with data from a previous trial. METHODS: One hundred ninety-nine emergency subjects diagnosed with IP of a mandibular molar were selected and received an IANB with 4% articaine. Subjects who failed to achieve profound pulpal anesthesia, determined by a positive response to cold or pain upon access, randomly received 4% articaine or 2% lidocaine as a supplemental BI. Endodontic access was begun 5 minutes after infiltration. Success was defined as less than mild pain during endodontic access and instrumentation on the Heft-Parker visual analog scale. RESULTS: There was a 25% IANB success rate with 4% articaine. The success rate for articaine supplemental BI in first molars was 61% versus 63% for second molars (P > .05). The success of lidocaine in first molars was 66%, but for second molars it was 32% (P = .004). CONCLUSIONS: The success rate for IANB with 4% articaine was 25%. Articaine and lidocaine had similar success rates for supplemental infiltration in first molars, whereas articaine was significantly more successful for second molars. However, because BI often did not provide profound pulpal anesthesia, additional techniques including intraosseous anesthesia may still be required.